Provider Demographics
NPI:1548234073
Name:KHAN, NOORUN M (MD)
Entity Type:Individual
Prefix:
First Name:NOORUN
Middle Name:M
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:PO BOX 393
Mailing Address - Street 2:
Mailing Address - City:WORTH
Mailing Address - State:IL
Mailing Address - Zip Code:60482-0393
Mailing Address - Country:US
Mailing Address - Phone:630-551-1097
Mailing Address - Fax:630-551-1097
Practice Address - Street 1:7600 W COLLEGE DR
Practice Address - Street 2:2ND FLOOR
Practice Address - City:PALOS HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60463-1001
Practice Address - Country:US
Practice Address - Phone:708-671-1800
Practice Address - Fax:708-671-1803
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-13
Last Update Date:2012-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036096079207Q00000X, 207R00000X, 207ZH0000X, 208100000X, 2085R0202X, 208600000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207ZH0000XAllopathic & Osteopathic PhysiciansPathologyHematology
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
579020Medicare ID - Type Unspecified
ILG79483Medicare UPIN