Provider Demographics
NPI:1780923490
Name:FAREESA KHAN LLC
Entity type:Organization
Organization Name:FAREESA KHAN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:FAREESA
Authorized Official - Middle Name:G
Authorized Official - Last Name:KHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:636-675-3107
Mailing Address - Street 1:PO BOX 410085
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-0085
Mailing Address - Country:US
Mailing Address - Phone:636-675-3107
Mailing Address - Fax:
Practice Address - Street 1:10004 KENNERLY RD STE 255A
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-2184
Practice Address - Country:US
Practice Address - Phone:314-270-9880
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-01
Last Update Date:2020-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO112917207VF0040X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VF0040XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyUrogynecology and Reconstructive Pelvic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO203820014Medicaid
MA1835009Medicare PIN
126188Medicare UPIN