Basic Information
| Provider Information | |||||||||
| NPI: | 1689212854 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KHALID | ||||||||
| FirstName: | RUMMAN | ||||||||
| MiddleName: | AHMED | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8201 E. RIVERSIDE BLVD. | ||||||||
| Address2: | JAVON BEA HOSPITAL-RIVERSIDE | ||||||||
| City: | ROCKFORD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 61114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8159717000 | ||||||||
| FaxNumber: | 8159719795 | ||||||||
| Practice Location | |||||||||
| Address1: | 2400 N. ROCKTON AVE. | ||||||||
| Address2: | JAVON BEA HOSPITAL- ROCKTON | ||||||||
| City: | ROCKFORD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 61103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8159715000 | ||||||||
| FaxNumber: | 8159719795 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/18/2019 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 05/28/2021 | ||||||||
| NPIReactivationDate: | 04/19/2022 | ||||||||
| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.