Healthcare Provider Details

I. General information

NPI: 1104860436
Provider Name (Legal Business Name): SURESH KHILNANI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2006
Last Update Date: 03/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1906 BLAKE AVE
GLENWOOD SPGS CO
81601-4227
US

IV. Provider business mailing address

1906 BLAKE AVE
GLENWOOD SPGS CO
81601-4227
US

V. Phone/Fax

Practice location:
  • Phone: 970-384-7707
  • Fax: 970-384-8141
Mailing address:
  • Phone: 970-384-7707
  • Fax: 970-384-8141

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number6268
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number52537
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: