Healthcare Provider Details

I. General information

NPI: 1376617498
Provider Name (Legal Business Name): AHMED RAZA KHAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2006
Last Update Date: 05/15/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HENRY FORD HEALTH SYSTEM 2799 WEST GRAND BOULEVARD
DETROIT MI
48202
US

IV. Provider business mailing address

601 ELMWOOD AVENUE BOX 604
ROCHESTER NY
14642-0001
US

V. Phone/Fax

Practice location:
  • Phone: 313-916-2436
  • Fax:
Mailing address:
  • Phone: 585-275-2141
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number058157
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number058157
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License Number058157
License Number StateMI
# 4
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number186875
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: