Healthcare Provider Details

I. General information

NPI: 1063844959
Provider Name (Legal Business Name): MOHAMMED HASAN KHAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2013
Last Update Date: 06/18/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13011 S 104TH AVE STE 100
PALOS PARK IL
60464-1508
US

IV. Provider business mailing address

13011 S 104TH AVE STE 100
PALOS PARK IL
60464-1508
US

V. Phone/Fax

Practice location:
  • Phone: 708-478-3600
  • Fax: 708-274-3299
Mailing address:
  • Phone: 708-478-3600
  • Fax: 708-274-3299

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number036.177944
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number006628
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number53688
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: