=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366837007
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KHANSA AHMAD M.D
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/31/2015
-----------------------------------------------------
Last Update Date | 10/31/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4600 N CLARENDON AVE APT 508
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60640-5749
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-477-6443
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4440W 95TH ST
-----------------------------------------------------
City | OAK LAWN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60453-2600
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-684-8000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RC0000X
-----------------------------------------------------
Taxonomy Name | Cardiovascular Disease Physician
-----------------------------------------------------
License Number | 1019208
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------