1477592905 NPI number — MONIRUZZAMAN KHAN MD

Table of content: MONIRUZZAMAN KHAN MD (NPI 1477592905)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477592905 NPI number — MONIRUZZAMAN KHAN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KHAN
Provider First Name:
MONIRUZZAMAN
Provider Middle Name:
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:
1477592905
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/13/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4402 E 9 MILE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WARREN
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48091-2590
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
586-200-0611
Provider Business Mailing Address Fax Number:
586-381-7055

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4402 E 9 MILE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WARREN
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48091-2590
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
586-200-0611
Provider Business Practice Location Address Fax Number:
586-381-7055
Provider Enumeration Date:
06/06/2006

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: 208D00000X , with the licence number:  MK057394 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0634011 . This is a "BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: G97370 . This is a "HEALTH ALLIANCE PLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1215B . This is a "CAPE HEALTH PLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 15486 . This is a "HEALTH PLAN OF MICH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 414952410 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 120911 . This is a "CARE CHOICE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 6251 . This is a "TOTAL HEALTH" identifier . This identifiers is of the category "OTHER".
  • Identifier: P105053 . This is a "BCN" identifier . This identifiers is of the category "OTHER".
  • Identifier: C7543 . This is a "MCARE" identifier . This identifiers is of the category "OTHER".




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