MEDICARE: ILLIANA PSYCHIATRIC ASSOCIATES INC PC

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	103TC0700X	Clinical Psychologist	01038685	IN

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	:	1811291248
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ILLIANA PSYCHIATRIC ASSOCIATES INC PC

Provider Business Mailing Address
First Line	:	4320 FIR ST
Second Line	:	SUITE 307
City	:	EAST CHICAGO
State	:	IN
Zip	:	46312-3052
Country	:	US
Telephone Number	:	219-397-6369
Fax Number	:	219-440-7240

Provider Business Practice Location Address
First Line	:	2010 E COLUMBUS DR
Second Line	:
City	:	EAST CHICAGO
State	:	IN
Zip	:	46312-2830
Country	:	US
Telephone Number	:	219-397-6369
Fax Number	:	219-440-7240

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. FARZANA A KHAN
Credential	:	M.D.
Telephone Number	:	219-455-8155

Provider Enumeration Date	:	12/28/2010
Last Update Date	:	06/28/2019

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