Healthcare Provider Details

I. General information

NPI: 1528089158
Provider Name (Legal Business Name): ALI A KHAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2006
Last Update Date: 12/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 HARTMAN PLZ
BUCKHANNON WV
26201-2230
US

IV. Provider business mailing address

527 MEDICAL PARK DRIVE SUITE 204
BRIDGEPORT WV
26330
US

V. Phone/Fax

Practice location:
  • Phone: 304-471-3400
  • Fax: 304-471-3402
Mailing address:
  • Phone: 304-933-3800
  • Fax: 304-933-3815

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number17611
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: