=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104481159
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMJAD RAZA KHAN DPM
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/06/2019
-----------------------------------------------------
Last Update Date | 11/18/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | ATLAS MEDICAL GROUP 245 E WARWICK DR
-----------------------------------------------------
City | ALMA
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48801
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-463-2150
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 22335 NIXON AVE
-----------------------------------------------------
City | BROWNSTOWN
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48193-8251
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-250-0427
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number | 5901400545
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------