Provider Demographics
NPI:1366808503
Name:KHAN, RAFEDA
Entity type:Individual
Prefix:
First Name:RAFEDA
Middle Name:
Last Name:KHAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 S BUFFALO GROVE RD
Mailing Address - Street 2:
Mailing Address - City:BUFFALO GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60089-2180
Mailing Address - Country:US
Mailing Address - Phone:224-715-6763
Mailing Address - Fax:
Practice Address - Street 1:1225 W DUNDEE RD
Practice Address - Street 2:
Practice Address - City:BUFFALO GROVE
Practice Address - State:IL
Practice Address - Zip Code:60089-4009
Practice Address - Country:US
Practice Address - Phone:847-368-1998
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-04
Last Update Date:2016-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051299207251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL051299207Medicaid