Provider Demographics
NPI:1700856929
Name:KHAN, ALI (MD)
Entity Type:Individual
Prefix:
First Name:ALI
Middle Name:
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 65274
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28265-0274
Mailing Address - Country:US
Mailing Address - Phone:800-377-8721
Mailing Address - Fax:304-523-2241
Practice Address - Street 1:921 E FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:KENTON
Practice Address - State:OH
Practice Address - Zip Code:43326-2020
Practice Address - Country:US
Practice Address - Phone:419-673-0761
Practice Address - Fax:419-673-9366
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-23
Last Update Date:2008-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-082837207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000187190OtherBCBS
OH000000376518OtherBLUECROSS BLUESHIELD
OH2442100Medicaid
P00184172OtherRR MCR
OHKH4131555Medicare PIN
H97656Medicare UPIN
OH4131553Medicare PIN