Basic Information
| Provider Information | |||||||||
| NPI: | 1982674347 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HANNA | ||||||||
| FirstName: | MILAD | ||||||||
| MiddleName: | HELMY | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ATTIATALLA | ||||||||
| OtherFirstName: | MILAD | ||||||||
| OtherMiddleName: | HELMY HANNA | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3702 NEW VISION DR BLDG B | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468451703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 8175 W US HIGHWAY 20 | ||||||||
| Address2: | |||||||||
| City: | SHIPSHEWANA | ||||||||
| State: | IN | ||||||||
| PostalCode: | 46565 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2607687432 | ||||||||
| FaxNumber: | 2607687482 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2006 | ||||||||
| LastUpdateDate: | 10/03/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 4301105158 | MI | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 01073600A | IN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1982674347 | 05 | MI | MEDICAID |