Provider Demographics
NPI:1205905197
Name:NGO, KHAI (MD)
Entity type:Individual
Prefix:MR
First Name:KHAI
Middle Name:
Last Name:NGO
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 1:4600 MEMORIAL DRIVE
Mailing Address - Street 2:SUITE 280
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62276
Mailing Address - Country:US
Mailing Address - Phone:618-257-2800
Mailing Address - Fax:618-257-9802
Practice Address - Street 1:4600 MEMORIAL DRIVE
Practice Address - Street 2:SUITE 280
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62276-5366
Practice Address - Country:US
Practice Address - Phone:618-257-2800
Practice Address - Fax:618-257-9802
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036079985208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036079985Medicaid
IL036079985Medicaid