Provider Demographics
NPI:1881826253
Name:M RAZA KHAN M D S C
Entity Type:Organization
Organization Name:M RAZA KHAN M D S C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MOHAMMAD
Authorized Official - Middle Name:RAZA
Authorized Official - Last Name:KHAN
Authorized Official - Suffix:
Authorized Official - Credentials:M D
Authorized Official - Phone:847-488-0123
Mailing Address - Street 1:450 SHEPARD DR
Mailing Address - Street 2:SUITE 9
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60123-7033
Mailing Address - Country:US
Mailing Address - Phone:847-488-0123
Mailing Address - Fax:847-488-0124
Practice Address - Street 1:1 S VIRGINIA ST
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-5826
Practice Address - Country:US
Practice Address - Phone:815-893-7975
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-18
Last Update Date:2009-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036118940207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1801937545OtherPERSONAL NPI #
IL036118940Medicaid
1801937545OtherPERSONAL NPI #