Provider Demographics
NPI:1417164062
Name:KHAN, KHURRAM JEHANGIR (MD)
Entity Type:Individual
Prefix:DR
First Name:KHURRAM
Middle Name:JEHANGIR
Last Name:KHAN
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 1:2228 STEEPLECHASE RD
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48188-2889
Mailing Address - Country:US
Mailing Address - Phone:617-504-6958
Mailing Address - Fax:888-959-3008
Practice Address - Street 1:200 N MADISON ST
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:MI
Practice Address - Zip Code:49068
Practice Address - Country:US
Practice Address - Phone:269-789-4386
Practice Address - Fax:269-789-4387
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA113983208100000X, 208VP0000X, 207QH0002X
MI4301083860208100000X, 2081P2900X, 208600000X, 208VP0014X, 207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA113983OtherCALIFORNIA MEDICAL LICENSE
MI1417164062Medicaid