Provider Demographics
NPI:1598068744
Name:MIRA KHENY MD LLC
Entity Type:Organization
Organization Name:MIRA KHENY MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MIRA
Authorized Official - Middle Name:
Authorized Official - Last Name:KHENY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:856-910-8100
Mailing Address - Street 1:PO BOX 1077
Mailing Address - Street 2:
Mailing Address - City:VOORHEES
Mailing Address - State:NJ
Mailing Address - Zip Code:08043-7077
Mailing Address - Country:US
Mailing Address - Phone:856-910-8100
Mailing Address - Fax:856-910-8101
Practice Address - Street 1:6650 BROWNING RD
Practice Address - Street 2:SUITE M21
Practice Address - City:PENNSAUKEN
Practice Address - State:NJ
Practice Address - Zip Code:08109-1479
Practice Address - Country:US
Practice Address - Phone:856-910-8100
Practice Address - Fax:856-910-8101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-09
Last Update Date:2010-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA04506900207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty