Basic Information
| Provider Information | |||||||||
| NPI: | 1801088992 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HAMDAN | ||||||||
| FirstName: | SHADI | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3100 SHORE DR | ||||||||
| Address2: | |||||||||
| City: | MARINETTE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 541434242 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7157354200 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3100 SHORE DR | ||||||||
| Address2: | |||||||||
| City: | MARINETTE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 541434242 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7157354200 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2007 | ||||||||
| LastUpdateDate: | 10/21/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | 60658 | WI | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | 207R00000X | 60658 | WI | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 12518401 | 01 | WI | CAQH/ REF NUMBER FOR BLUE CROSS BLUE SHILED | OTHER |