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General NPI Number Information
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NPI Number | 1780923490
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Entity Type | Organization
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Legal Business Name | FAREESA KHAN LLC
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Dates
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Enumeration Date | 02/01/2013
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Last Update Date | 07/10/2020
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Provider Practice Location Address
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Address Line | 10004 KENNERLY RD STE 255A
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City | SAINT LOUIS
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State | MO
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Zip | 63128-2184
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Country | US
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Telephone | 314-270-9880
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 410085
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City | SAINT LOUIS
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State | MO
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Zip | 63141-0085
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Country | US
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Telephone | 636-675-3107
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | FAREESA G KHAN
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Credential | MD
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Telephone | 636-675-3107
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207VF0040X
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Taxonomy Name | Urogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician
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License Number | 112917
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License Number State | MO
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