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General NPI Number Information
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NPI Number | 1235284076
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Entity Type | Organization
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Legal Business Name | CREEKSIDE INTERNAL MEDICINE
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Dates
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Enumeration Date | 01/24/2007
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 358 68TH ST SW
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City | GRAND RAPIDS
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State | MI
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Zip | 49548-7179
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Country | US
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Telephone | 616-281-0463
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Fax | 616-281-0576
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Provider Business Mailing Address
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Address Line | 358 68TH ST SW
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City | GRAND RAPIDS
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State | MI
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Zip | 49548-7179
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Country | US
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Telephone | 616-281-0463
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Fax | 616-281-0576
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. KHAN KHAN
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Credential | M.D.
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Telephone | 616-954-0600
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number |
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License Number State | MI
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