Provider Demographics
NPI:1417198011
Name:AHMED KHAN, MOHAMMED ILYAS (MD,)
Entity Type:Individual
Prefix:
First Name:MOHAMMED ILYAS
Middle Name:
Last Name:AHMED 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 1:2400 N ROCKTON AVE
Mailing Address - Street 2:PALLIATIVE CARE
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61103-3655
Mailing Address - Country:US
Mailing Address - Phone:915-971-5000
Mailing Address - Fax:815-968-9677
Practice Address - Street 1:2400 N ROCKTON AVE
Practice Address - Street 2:PALLIATIVE CARE
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61103-3655
Practice Address - Country:US
Practice Address - Phone:815-971-5000
Practice Address - Fax:815-968-9677
Is Sole Proprietor?:No
Enumeration Date:2009-03-12
Last Update Date:2014-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.093467207RH0002X
IL036135854207RH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3058131Medicaid