Provider Demographics
NPI:1164846739
Name:INTERNAL MEDICINE OF DEARBORN
Entity type:Organization
Organization Name:INTERNAL MEDICINE OF DEARBORN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:SHABANA
Authorized Official - Middle Name:
Authorized Official - Last Name:KHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:313-565-8950
Mailing Address - Street 1:831 MONROE ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-2308
Mailing Address - Country:US
Mailing Address - Phone:313-565-8950
Mailing Address - Fax:313-769-5931
Practice Address - Street 1:831 MONROE ST
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-2308
Practice Address - Country:US
Practice Address - Phone:313-565-8950
Practice Address - Fax:313-769-5931
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-18
Last Update Date:2014-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301046990207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1164846739Medicaid
MIM17689002Medicare PIN
M17689001Medicare PIN