Provider Demographics
NPI:1538268628
Name:KHUSRO, QAZI E (MD)
Entity type:Individual
Prefix:
First Name:QAZI
Middle Name:E
Last Name:KHUSRO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 W UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61820-3981
Mailing Address - Country:US
Mailing Address - Phone:217-366-6162
Mailing Address - Fax:217-366-6106
Practice Address - Street 1:3101 FIELDS SOUTH DR
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61822-3743
Practice Address - Country:US
Practice Address - Phone:217-366-5642
Practice Address - Fax:217-366-6106
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2022-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36081816207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL201622626001Medicaid
IL0360818161Medicaid
IL0360818161Medicaid
ILK20067Medicare PIN
IL201622626001Medicaid
IL205226Medicare PIN
ILF38929Medicare UPIN
ILP00321576Medicare PIN