Basic Information
| Provider Information | |||||||||
| NPI: | 1861438434 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HASSELMAN | ||||||||
| FirstName: | TY | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 420 NE GLEN OAK AVE | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | PEORIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 616033105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3096553453 | ||||||||
| FaxNumber: | 3096553410 | ||||||||
| Practice Location | |||||||||
| Address1: | 420 NE GLEN OAK AVE | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | PEORIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 616033105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3096553453 | ||||||||
| FaxNumber: | 3096553410 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2006 | ||||||||
| LastUpdateDate: | 09/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0202X | 036-106293 | IL | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Cardiology |
ID Information
| ID | Type | State | Issuer | Description | 036106293 | 05 | IL | MEDICAID |