MEDICARE: NAEEM A KHAN MD SC

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	207RC0000X	Cardiovascular Disease Physician	036064097	IL

General Provider Information

NPI Number	:	1790810216
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NAEEM A KHAN MD SC

Provider Business Mailing Address
First Line	:	1050 M L KING DR
Second Line	:	SUITE 108
City	:	CENTRALIA
State	:	IL
Zip	:	62801-3060
Country	:	US
Telephone Number	:	618-532-3517
Fax Number	:	618-532-0801

Provider Business Practice Location Address
First Line	:	1050 M L KING DR
Second Line	:	SUITE 108
City	:	CENTRALIA
State	:	IL
Zip	:	62801-3060
Country	:	US
Telephone Number	:	618-532-3517
Fax Number	:	618-532-0801

Authorized Official
Title or Position	:	OWNER
Name	:	DR. NAEEM ANWAR KHAN
Credential	:	MD
Telephone Number	:	618-532-3517

Provider Enumeration Date	:	02/23/2007
Last Update Date	:	05/24/2012

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