Healthcare Provider Details

I. General information

NPI: 1669931432
Provider Name (Legal Business Name): TUSHAR KHANNA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/19/2019
Last Update Date: 09/02/2026
Certification Date: 09/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22250 PROVIDENCE DR STE 301A
SOUTHFIELD MI
48075-6211
US

IV. Provider business mailing address

3400 SPRUCE ST
PHILADELPHIA PA
19104-4238
US

V. Phone/Fax

Practice location:
  • Phone: 248-849-3254
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number4301514012
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number4301514012
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberMD481430
License Number StatePA
# 4
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD481430
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: