Provider Demographics
NPI:1932441631
Name:ILLIANA PSYCHIATRIC ASSOCIATES
Entity Type:Organization
Organization Name:ILLIANA PSYCHIATRIC ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
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:219-397-6369
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:219-455-8155
Mailing Address - Fax:
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:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-20
Last Update Date:2019-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1038685103TP0016X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TP0016XBehavioral Health & Social Service ProvidersPsychologistPrescribing (Medical)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100325130Medicaid
INM100061228Medicare PIN