Provider Demographics
NPI:1194770065
Name:HASSAN, MOUSTAFA A (MD)
Entity type:Individual
Prefix:
First Name:MOUSTAFA
Middle Name:A
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 1:750 E ADAMS ST
Mailing Address - Street 2:DEPARTMENT OF SURGERY
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13210-2306
Mailing Address - Country:US
Mailing Address - Phone:315-464-1800
Mailing Address - Fax:315-464-6252
Practice Address - Street 1:750 E ADAMS ST
Practice Address - Street 2:DEPARTMENT OF SURGERY
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-2306
Practice Address - Country:US
Practice Address - Phone:315-464-1800
Practice Address - Fax:315-464-6252
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2013-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2439282086S0127X, 2086S0102X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
No2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08973733Medicaid
AL51526800OtherBLUE CROSS
AL17-00359OtherUNITED HEALTH CARE
FL272003500Medicaid
AL009983735Medicaid
AL51526801OtherBLUE CROSS
AL009983745Medicaid
NY02870955Medicaid
H50859Medicare UPIN
MS08973733Medicaid
NYRB4230Medicare PIN