Healthcare Provider Details

I. General information

NPI: 1780923490
Provider Name (Legal Business Name): FAREESA KHAN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2013
Last Update Date: 07/10/2020
Certification Date: 07/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10004 KENNERLY RD STE 255A
SAINT LOUIS MO
63128-2184
US

IV. Provider business mailing address

PO BOX 410085
SAINT LOUIS MO
63141-0085
US

V. Phone/Fax

Practice location:
  • Phone: 314-270-9880
  • Fax:
Mailing address:
  • Phone: 636-675-3107
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VF0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician
License Number112917
License Number StateMO

VIII. Authorized Official

Name: FAREESA G KHAN
Title or Position: OWNER
Credential: MD
Phone: 636-675-3107