Provider Demographics
NPI:1639354780
Name:LIBERTY MEDICAL CENTER OF MINOOKA, SC
Entity Type:Organization
Organization Name:LIBERTY MEDICAL CENTER OF MINOOKA, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:AFTAB
Authorized Official - Middle Name:A
Authorized Official - Last Name:KHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-521-1010
Mailing Address - Street 1:603 W MONDAMIN ST
Mailing Address - Street 2:
Mailing Address - City:MINOOKA
Mailing Address - State:IL
Mailing Address - Zip Code:60447-9057
Mailing Address - Country:US
Mailing Address - Phone:815-521-1010
Mailing Address - Fax:815-521-1826
Practice Address - Street 1:603 W MONDAMIN ST
Practice Address - Street 2:
Practice Address - City:MINOOKA
Practice Address - State:IL
Practice Address - Zip Code:60447-9057
Practice Address - Country:US
Practice Address - Phone:815-521-1010
Practice Address - Fax:815-521-1826
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-08
Last Update Date:2008-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty