Basic Information
| Provider Information | |||||||||
| NPI: | 1700856929 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KHAN | ||||||||
| FirstName: | ALI | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 65274 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282650274 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003778721 | ||||||||
| FaxNumber: | 3045232241 | ||||||||
| Practice Location | |||||||||
| Address1: | 921 E FRANKLIN ST | ||||||||
| Address2: | |||||||||
| City: | KENTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 433262020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4196730761 | ||||||||
| FaxNumber: | 4196739366 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2006 | ||||||||
| LastUpdateDate: | 02/28/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 35-082837 | OH | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000000187190 | 01 | OH | BCBS | OTHER | 000000376518 | 01 | OH | BLUECROSS BLUESHIELD | OTHER | 2442100 | 05 | OH | MEDICAID | P00184172 | 01 | RR MCR | OTHER |