Provider Demographics
NPI:1598870503
Name:KHAN, ALI A (MD)
Entity Type:Individual
Prefix:
First Name:ALI
Middle Name:A
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 1:168 N CASEVILLE RD
Mailing Address - Street 2:
Mailing Address - City:PIGEON
Mailing Address - State:MI
Mailing Address - Zip Code:48755-9704
Mailing Address - Country:US
Mailing Address - Phone:989-453-3585
Mailing Address - Fax:989-453-3074
Practice Address - Street 1:168 N CASEVILLE RD
Practice Address - Street 2:
Practice Address - City:PIGEON
Practice Address - State:MI
Practice Address - Zip Code:48755-9704
Practice Address - Country:US
Practice Address - Phone:989-453-3585
Practice Address - Fax:989-453-3074
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-20
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301053789207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3121082Medicaid
MI3121082Medicaid
MIF01698Medicare UPIN