Basic Information
Provider Information | |||||||||
NPI: | 1457582926 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HASANAT | ||||||||
FirstName: | REWA | ||||||||
MiddleName: | MAHMOUD | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 27702 NETWORK PL | ||||||||
Address2: |   | ||||||||
City: | CHICAGO | ||||||||
State: | IL | ||||||||
PostalCode: | 606731277 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7088627674 | ||||||||
FaxNumber: | 7088621781 | ||||||||
Practice Location | |||||||||
Address1: | 6703 159TH ST | ||||||||
Address2: | SUITE 103 | ||||||||
City: | TINLEY PARK | ||||||||
State: | IL | ||||||||
PostalCode: | 604771781 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7083423000 | ||||||||
FaxNumber: | 7083423060 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/01/2009 | ||||||||
LastUpdateDate: | 12/19/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 036131285 | IL | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 231199026 | 01 | IL | MEDICARE | OTHER | 036131285 | 05 | IL |   | MEDICAID | P01148828 | 01 | IL | RRM | OTHER |