Provider Demographics
NPI:1568609246
Name:KHAN, SHAHID ALI (DC)
Entity Type:Individual
Prefix:DR
First Name:SHAHID
Middle Name:ALI
Last Name:KHAN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:DR
Other - First Name:MOHAMMAD
Other - Middle Name:SHAHID
Other - Last Name:KHAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DC
Mailing Address - Street 1:27850 GRATIOT AVE
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48066-4803
Mailing Address - Country:US
Mailing Address - Phone:586-772-5876
Mailing Address - Fax:586-772-1122
Practice Address - Street 1:27850 GRATIOT AVE
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48066-4803
Practice Address - Country:US
Practice Address - Phone:586-772-5876
Practice Address - Fax:586-772-1122
Is Sole Proprietor?:No
Enumeration Date:2009-01-16
Last Update Date:2011-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301009421111N00000X, 111NR0400X, 111NX0100X, 111NP0017X, 111NI0013X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No111NR0400XChiropractic ProvidersChiropractorRehabilitation
No111NX0100XChiropractic ProvidersChiropractorOccupational Health
No111NP0017XChiropractic ProvidersChiropractorPediatric Chiropractor
No111NI0013XChiropractic ProvidersChiropractorIndependent Medical Examiner
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMK009421OtherBCBS OF MI
MI68504OtherHEALTH PLAN OF MICHIGAN
MIMK009421OtherBCBS OF MI