Provider Demographics
NPI:1174625214
Name:MUKHTAR A KHAN MD,FACC,PC
Entity type:Organization
Organization Name:MUKHTAR A KHAN MD,FACC,PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:MUKHTAR
Authorized Official - Middle Name:AHMAD
Authorized Official - Last Name:KHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD,FACC,CBNC,,PC
Authorized Official - Phone:586-774-0700
Mailing Address - Street 1:25779 KELLY RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:ROSEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48066-4973
Mailing Address - Country:US
Mailing Address - Phone:586-774-0700
Mailing Address - Fax:586-774-9841
Practice Address - Street 1:25779 KELLY RD
Practice Address - Street 2:SUITE C
Practice Address - City:ROSEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48066-4973
Practice Address - Country:US
Practice Address - Phone:586-774-0700
Practice Address - Fax:586-774-9841
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIMK044345207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2898009Medicaid
MI2898009Medicaid
MIA78196Medicare UPIN