Basic Information
| Provider Information | |||||||||
| NPI: | 1689089674 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HASAN | ||||||||
| FirstName: | SYED | ||||||||
| MiddleName: | MURTAZA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1200 W WHITE RIVER BLVD | ||||||||
| Address2: | RCS PROVIDER ENROLLMENT | ||||||||
| City: | MUNCIE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 473034988 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8776685621 | ||||||||
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| Practice Location | |||||||||
| Address1: | 10215 AUBURN PARK DR | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468252387 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2602345400 | ||||||||
| FaxNumber: | 2602345110 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2014 | ||||||||
| LastUpdateDate: | 01/08/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 01077419A | IN | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207Q00000X | 01077419A | IN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.