Basic Information
| Provider Information | |||||||||
| NPI: | 1063440220 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HANNA | ||||||||
| FirstName: | AIDA | ||||||||
| MiddleName: | MALLOUHI | ||||||||
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| Credential: | M.D.. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 680 CENTRE ST | ||||||||
| Address2: | |||||||||
| City: | BROCKTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023023308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5089417268 | ||||||||
| FaxNumber: | 5089416156 | ||||||||
| Practice Location | |||||||||
| Address1: | 130 QUINCY AVE | ||||||||
| Address2: | |||||||||
| City: | BROCKTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023022803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5089417268 | ||||||||
| FaxNumber: | 5089417850 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2006 | ||||||||
| LastUpdateDate: | 02/27/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 203922 | MA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2031558 | 05 | MA | MEDICAID |