Provider Demographics
NPI:1093749699
Name:PATHAN, AMANULLAH KHAN (MD)
Entity Type:Individual
Prefix:
First Name:AMANULLAH
Middle Name:KHAN
Last Name:PATHAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4600 MEMORIAL DRIVE
Mailing Address - Street 2:MEDICAL CENTER 2 SUITE 420
Mailing Address - City:BELLEVEILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62226-5366
Mailing Address - Country:US
Mailing Address - Phone:618-239-3356
Mailing Address - Fax:618-239-3359
Practice Address - Street 1:4600 MEMORIAL DRIVE
Practice Address - Street 2:MEDICAL CENTER 2 SUITE 420
Practice Address - City:BELLEVEILLE
Practice Address - State:IL
Practice Address - Zip Code:62226-5366
Practice Address - Country:US
Practice Address - Phone:618-239-3356
Practice Address - Fax:618-239-3359
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2010-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036060909207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
146897XXOtherPREFERRED CARE
IL08200472OtherBCBS
PA1495152OtherBCBS
CA5095060029745OtherRR MEDICARE
101463OtherHEALTHLINK
2102754OtherAETNA
IL036060909Medicaid
060029745OtherRR MEDICARE
0938287001OtherCIGNA
MO100789OtherBCBS
140491OtherPHCS
7661OtherGHP CMR
2507179OtherUHC
D14712OtherMERCY HEALTH PLAN
146897XXOtherPREFERRED CARE
060029745OtherRR MEDICARE
2102754OtherAETNA