Provider Demographics
NPI:1811656028
Name:KHAN, SHAHREQ ALI (BACHELOR OF SCIENCE)
Entity type:Individual
Prefix:
First Name:SHAHREQ
Middle Name:ALI
Last Name:KHAN
Suffix:
Gender:M
Credentials:BACHELOR OF SCIENCE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3949 GROVE AVE
Mailing Address - Street 2:
Mailing Address - City:GURNEE
Mailing Address - State:IL
Mailing Address - Zip Code:60031-2118
Mailing Address - Country:US
Mailing Address - Phone:224-202-7777
Mailing Address - Fax:
Practice Address - Street 1:3949 GROVE AVE
Practice Address - Street 2:
Practice Address - City:GURNEE
Practice Address - State:IL
Practice Address - Zip Code:60031-2118
Practice Address - Country:US
Practice Address - Phone:224-202-7777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-15
Last Update Date:2022-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL14D2250825261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center