MEDICARE: MR. IMRAN A KHAN BCBA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst	1-09-6640	IL

General Provider Information

NPI Number	:	1073837738
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. IMRAN A KHAN BCBA

Provider Business Mailing Address
First Line	:	857 N MARSHFIELD AVE
Second Line	:	APT 3
City	:	CHICAGO
State	:	IL
Zip	:	60622-5132
Country	:	US
Telephone Number	:	312-513-5052
Fax Number	:

Provider Business Practice Location Address
First Line	:	857 N MARSHFIELD AVE
Second Line	:	APT 3
City	:	CHICAGO
State	:	IL
Zip	:	60622-5132
Country	:	US
Telephone Number	:	312-513-5052
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/23/2010
Last Update Date	:	03/23/2010

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