Healthcare Provider Details

I. General information

NPI: 1417164062
Provider Name (Legal Business Name): KHURRAM JEHANGIR KHAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2007
Last Update Date: 01/21/2025
Certification Date: 01/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 N MADISON ST
MARSHALL MI
49068
US

IV. Provider business mailing address

2228 STEEPLECHASE RD
CANTON MI
48188-2889
US

V. Phone/Fax

Practice location:
  • Phone: 269-789-4386
  • Fax: 269-789-4387
Mailing address:
  • Phone: 617-504-6958
  • Fax: 888-959-3008

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number4301083860
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number4301083860
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License NumberA113983
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number4301083860
License Number StateMI
# 5
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberA113983
License Number StateCA
# 6
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number4301083860
License Number StateMI
# 7
Primary TaxonomyN
Taxonomy Code207QH0002X
TaxonomyHospice and Palliative Medicine (Family Medicine) Physician
License NumberA113983
License Number StateCA
# 8
Primary TaxonomyN
Taxonomy Code2081H0002X
TaxonomyHospice and Palliative Medicine (Physical Medicine & Rehabilitation) Physician
License Number04-47511
License Number StateKS
# 9
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number4301083860
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: