Basic Information
Provider Information | |||||||||
NPI: | 1639675655 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HASSAN | ||||||||
FirstName: | MOHAMED | ||||||||
MiddleName: | SALAH M. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1070 LOCKWOOD DR | ||||||||
Address2: |   | ||||||||
City: | BEAUMONT | ||||||||
State: | TX | ||||||||
PostalCode: | 777065549 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4096595289 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 3080 COLLEGE ST | ||||||||
Address2: |   | ||||||||
City: | BEAUMONT | ||||||||
State: | TX | ||||||||
PostalCode: | 777014606 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4092125000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/30/2018 | ||||||||
LastUpdateDate: | 08/18/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/18/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | T4383 | TX | Y |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   |
No ID Information.