Healthcare Provider Details

I. General information

NPI: 1669747374
Provider Name (Legal Business Name): KAILASH KHIANI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: KAILASH KHIANI M.D.

II. Dates (important events)

Enumeration Date: 03/13/2012
Last Update Date: 06/06/2024
Certification Date: 06/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1350 WALTON WAY
AUGUSTA GA
30901-2612
US

IV. Provider business mailing address

1350 WALTON WAY
AUGUSTA GA
30901-2612
US

V. Phone/Fax

Practice location:
  • Phone: 706-774-8808
  • Fax:
Mailing address:
  • Phone: 706-774-8808
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number69479
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number069479
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number265627
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: