Provider Demographics
NPI:1134477748
Name:KHAN, KANIZ RASUL (MD)
Entity Type:Individual
Prefix:DR
First Name:KANIZ
Middle Name:RASUL
Last Name:KHAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1068 W BALTIMORE PIKE
Mailing Address - Street 2:
Mailing Address - City:MEDIA
Mailing Address - State:PA
Mailing Address - Zip Code:19063-5104
Mailing Address - Country:US
Mailing Address - Phone:610-566-9400
Mailing Address - Fax:610-627-4230
Practice Address - Street 1:130 S BRYN MAWR AVE
Practice Address - Street 2:H-WING, SUITE 321
Practice Address - City:BRYN MAWR
Practice Address - State:PA
Practice Address - Zip Code:19010-3121
Practice Address - Country:US
Practice Address - Phone:484-337-4097
Practice Address - Fax:484-337-4082
Is Sole Proprietor?:No
Enumeration Date:2012-08-29
Last Update Date:2017-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD446686207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA232359401OtherMLHC TIN