Provider Demographics
NPI:1811291248
Name:ILLIANA PSYCHIATRIC ASSOCIATES INC PC
Entity type:Organization
Organization Name:ILLIANA PSYCHIATRIC ASSOCIATES INC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:FARZANA
Authorized Official - Middle Name:A
Authorized Official - Last Name:KHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:219-455-8155
Mailing Address - Street 1:4320 FIR ST
Mailing Address - Street 2:SUITE 307
Mailing Address - City:EAST CHICAGO
Mailing Address - State:IN
Mailing Address - Zip Code:46312-3052
Mailing Address - Country:US
Mailing Address - Phone:219-397-6369
Mailing Address - Fax:219-440-7240
Practice Address - Street 1:2010 E COLUMBUS DR
Practice Address - Street 2:
Practice Address - City:EAST CHICAGO
Practice Address - State:IN
Practice Address - Zip Code:46312-2830
Practice Address - Country:US
Practice Address - Phone:219-397-6369
Practice Address - Fax:219-440-7240
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-28
Last Update Date:2019-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01038685103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100325130AMedicaid
IN138330Medicare PIN
IN96117Medicare UPIN