Provider Demographics
NPI:1710185426
Name:MANSOOR KHAN MD SC
Entity Type:Organization
Organization Name:MANSOOR KHAN MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MANSOOR
Authorized Official - Middle Name:
Authorized Official - Last Name:KHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-952-7181
Mailing Address - Street 1:1120 HUNTER ST
Mailing Address - Street 2:
Mailing Address - City:LOMBARD
Mailing Address - State:IL
Mailing Address - Zip Code:60148-4822
Mailing Address - Country:US
Mailing Address - Phone:847-952-7181
Mailing Address - Fax:847-437-8824
Practice Address - Street 1:800 BIESTERFIELD RD STE 407
Practice Address - Street 2:
Practice Address - City:ELK GROVE VILLAGE
Practice Address - State:IL
Practice Address - Zip Code:60007-3311
Practice Address - Country:US
Practice Address - Phone:847-952-7181
Practice Address - Fax:847-437-8824
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-03
Last Update Date:2009-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036093169207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILDO3620OtherRAILROAD MEDICARE
ILDO3620OtherRAILROAD MEDICARE
IL547880Medicare ID - Type Unspecified