Provider Demographics
NPI:1104810886
Name:HASSAN, SYED M (MD)
Entity type:Individual
Prefix:
First Name:SYED
Middle Name:M
Last Name:HASSAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 E APPLE ST
Mailing Address - Street 2:SUITE NW 3300
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45409-2939
Mailing Address - Country:US
Mailing Address - Phone:937-208-8394
Mailing Address - Fax:937-208-8388
Practice Address - Street 1:30 E APPLE ST
Practice Address - Street 2:SUITE NW 3300
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45409-2939
Practice Address - Country:US
Practice Address - Phone:937-208-8394
Practice Address - Fax:937-208-8388
Is Sole Proprietor?:No
Enumeration Date:2005-09-08
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036-112577207R00000X
IA35665207R00000X
OH35.097869207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
104474OtherHEALTH ALLIANCE #
IA1241593OtherCONTROLLED SUBSTANCE#
IA92087OtherIA BC/BS SEEN IN RI
IA92135OtherIA BC/BS SEEN IN MOLINE
ILIL01B2OtherJOHN DEERE EDI#
OH0054680Medicaid
IA0568980Medicaid
IA0568998Medicaid
IA421060724OtherBILLING TAX ID# FOR CHC
IL036112577Medicaid
IL336073336OtherCONTROLLED SUBSTANCE#
IL421060724B2OtherJOHN DEERE HEALTH
IL8122859OtherILLINOIS BC/BS
IA37768OtherIOWABC/BS SEEN IN RD
IL421060724005Medicaid
IL421060724005Medicaid
OH0054680Medicaid
OHH028750Medicare PIN
IA37768OtherIOWABC/BS SEEN IN RD
IA421060724OtherBILLING TAX ID# FOR CHC