Basic Information
| Provider Information | |||||||||
| NPI: | 1902814957 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HAFEZ | ||||||||
| FirstName: | WALID | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 927 BROADWAY | ||||||||
| Address2: | STE 302 | ||||||||
| City: | QUINCY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2172246423 | ||||||||
| FaxNumber: | 2172233641 | ||||||||
| Practice Location | |||||||||
| Address1: | 927 BROADWAY | ||||||||
| Address2: | STE 302 | ||||||||
| City: | QUINCY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2172246423 | ||||||||
| FaxNumber: | 2172233641 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2006 | ||||||||
| LastUpdateDate: | 12/27/2010 | ||||||||
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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 | 2084N0400X | 036056609 | IL | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0400X | 036.056609 | IL | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 036056609 | 05 | IL | MEDICAID |