Provider Demographics
NPI:1164076683
Name:FOREFRONT-KHATKHATE MEDICAL SERVICES PC
Entity Type:Organization
Organization Name:FOREFRONT-KHATKHATE MEDICAL SERVICES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT/PROVIDER ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:SHERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:KOVACS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-552-5232
Mailing Address - Street 1:6201 OAK CYN STE 150
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92618-5230
Mailing Address - Country:US
Mailing Address - Phone:949-552-5232
Mailing Address - Fax:888-972-2903
Practice Address - Street 1:600 S 2ND ST STE 404
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-2542
Practice Address - Country:US
Practice Address - Phone:510-201-0190
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-01
Last Update Date:2019-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036-119096OtherSTATE MEDICAL LICENSE