MEDICARE: FATIMA KHURRUM MD

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	207Q00000X	Family Medicine Physician	11012596	IN

General Provider Information

NPI Number	:	1609887942
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	FATIMA KHURRUM MD

Provider Business Mailing Address
First Line	:	2434 LAKE AVE
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46805-5406
Country	:	US
Telephone Number	:	260-423-2675
Fax Number	:	260-423-6621

Provider Business Practice Location Address
First Line	:	2434 LAKE AVE
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46805-5406
Country	:	US
Telephone Number	:	260-423-2675
Fax Number	:	260-423-6621

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

Provider Enumeration Date	:	08/11/2006
Last Update Date	:	07/08/2007

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