Basic Information
| Provider Information | |||||||||
| NPI: | 1194768432 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOOSA | ||||||||
| FirstName: | HANS | ||||||||
| MiddleName: | HASSAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4600 MEMORIAL DR STE 120 | ||||||||
| Address2: | |||||||||
| City: | BELLEVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622265359 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182221020 | ||||||||
| FaxNumber: | 6182221039 | ||||||||
| Practice Location | |||||||||
| Address1: | 4600 MEMORIAL DR STE 120 | ||||||||
| Address2: | |||||||||
| City: | BELLEVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622265359 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182221020 | ||||||||
| FaxNumber: | 6182221039 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2006 | ||||||||
| LastUpdateDate: | 03/25/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0129X | 036-073250 | IL | Y | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
ID Information
| ID | Type | State | Issuer | Description | 036073250 | 05 | IL | MEDICAID |