Provider Demographics
NPI:1306903851
Name:HAZIMAH, BASIL H (DPM)
Entity type:Individual
Prefix:
First Name:BASIL
Middle Name:H
Last Name:HAZIMAH
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 997
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62903-0997
Mailing Address - Country:US
Mailing Address - Phone:618-457-0431
Mailing Address - Fax:618-457-5199
Practice Address - Street 1:1235 CEDAR CT
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-5335
Practice Address - Country:US
Practice Address - Phone:618-457-0431
Practice Address - Fax:618-457-5199
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2008-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36003066H213ES0103X
IL0160053701213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL016005370Medicaid
ILCI5845OtherRAILROAD MEDICARE
IL03922239OtherBLUE CROSS/BLUE SHIELD
IL03922239OtherBLUE CROSS/BLUE SHIELD
IL0718600001Medicare NSC
IL016005370Medicaid