1063605293 NPI number — SANJAY J KHIANI MD

Table of content: SANJAY J KHIANI MD (NPI 1063605293)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063605293 NPI number — SANJAY J KHIANI MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KHIANI
Provider First Name:
SANJAY
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063605293
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/16/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10370 PARK RD
Provider Second Line Business Mailing Address:
SUITE 202
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28210-8508
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-817-2022
Provider Business Mailing Address Fax Number:
704-817-2024

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10370 PARK RD
Provider Second Line Business Practice Location Address:
SUITE 202
Provider Business Practice Location Address City Name:
CHARLOTTE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28210-8508
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-817-2022
Provider Business Practice Location Address Fax Number:
704-817-2024
Provider Enumeration Date:
08/21/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207K00000X , with the licence number:  51918 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207K00000X , with the licence number: 41230 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207K00000X , with the licence number: 2012-00056 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 35337600 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200874570 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200340800 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000541483 . This is a "ANTHEM PIN" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 9454082 . This is a "AETNA PIN" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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