Basic Information
| Provider Information | |||||||||
| NPI: | 1104810886 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HASSAN | ||||||||
| FirstName: | SYED | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 30 E APPLE ST | ||||||||
| Address2: | SUITE NW 3300 | ||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454092939 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372088394 | ||||||||
| FaxNumber: | 9372088388 | ||||||||
| Practice Location | |||||||||
| Address1: | 30 E APPLE ST | ||||||||
| Address2: | SUITE NW 3300 | ||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454092939 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372088394 | ||||||||
| FaxNumber: | 9372088388 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2005 | ||||||||
| LastUpdateDate: | 12/12/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 036-112577 | IL | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 35665 | IA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 35.097869 | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 104474 | 01 | HEALTH ALLIANCE # | OTHER | 1241593 | 01 | IA | CONTROLLED SUBSTANCE# | OTHER | 92087 | 01 | IA | IA BC/BS SEEN IN RI | OTHER | 92135 | 01 | IA | IA BC/BS SEEN IN MOLINE | OTHER | IL01B2 | 01 | IL | JOHN DEERE EDI# | OTHER | 0054680 | 05 | OH | MEDICAID | 0568980 | 05 | IA | MEDICAID | 0568998 | 05 | IA | MEDICAID | 421060724 | 01 | IA | BILLING TAX ID# FOR CHC | OTHER | 036112577 | 05 | IL | MEDICAID | 336073336 | 01 | IL | CONTROLLED SUBSTANCE# | OTHER | 421060724B2 | 01 | IL | JOHN DEERE HEALTH | OTHER | 8122859 | 01 | IL | ILLINOIS BC/BS | OTHER | BH7399581 | 01 | FEDERAL DEA# | OTHER | 37768 | 01 | IA | IOWABC/BS SEEN IN RD | OTHER | 421060724005 | 05 | IL | MEDICAID |