Provider Demographics
NPI:1922416171
Name:KHAN INTERNAL MEDICINE CENTER
Entity Type:Organization
Organization Name:KHAN INTERNAL MEDICINE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CLISTA
Authorized Official - Middle Name:P
Authorized Official - Last Name:TALLENT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-279-1356
Mailing Address - Street 1:1407 CHATTANOOGA AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:DALTON
Mailing Address - State:GA
Mailing Address - Zip Code:30720-2631
Mailing Address - Country:US
Mailing Address - Phone:706-279-1356
Mailing Address - Fax:706-279-1359
Practice Address - Street 1:1407 CHATTANOOGA AVE
Practice Address - Street 2:SUITE A
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30720-2631
Practice Address - Country:US
Practice Address - Phone:706-279-1356
Practice Address - Fax:706-279-1359
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-31
Last Update Date:2014-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA042315207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000728307OMedicaid
511G700738Medicare PIN