MEDICARE: DR. FAREESA G KHAN M.D.

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	207V00000X	Obstetrics & Gynecology Physician	112917	MO
2	207VF0040X	Urogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician	036104448	IL
3	2088F0040X	Urogynecology and Reconstructive Pelvic Surgery (Urology) Physician	036-104448	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1790702322
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. FAREESA G KHAN M.D.

Provider Business Mailing Address
First Line	:	1653 W CONGRESS PKWY # 230A
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60612-3833
Country	:	US
Telephone Number	:	312-942-6613
Fax Number	:

Provider Business Practice Location Address
First Line	:	1725 W HARRISON ST STE 1129
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60612-3841
Country	:	US
Telephone Number	:	312-942-6613
Fax Number	:

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

Provider Enumeration Date	:	07/17/2006
Last Update Date	:	02/28/2022

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