Basic Information
| Provider Information | |||||||||
| NPI: | 1588636435 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HABIB | ||||||||
| FirstName: | ISAM | ||||||||
| MiddleName: | HASAN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1155 W JEFFERSON ST STE 104 | ||||||||
| Address2: | |||||||||
| City: | FRANKLIN | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461312731 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3173467934 | ||||||||
| FaxNumber: | 3173462712 | ||||||||
| Practice Location | |||||||||
| Address1: | 1155 W JEFFERSON ST STE 202 | ||||||||
| Address2: | |||||||||
| City: | FRANKLIN | ||||||||
| State: | IN | ||||||||
| PostalCode: | 46131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3173463883 | ||||||||
| FaxNumber: | 3173463141 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/06/2006 | ||||||||
| LastUpdateDate: | 07/23/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RP1001X | 33631 | WI | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
| ID | Type | State | Issuer | Description | 200907990 | 05 | IN | MEDICAID |