Provider Demographics
NPI:1306938774
Name:EBRAHIM, HASSAN M (MD)
Entity type:Individual
Prefix:DR
First Name:HASSAN
Middle Name:M
Last Name:EBRAHIM
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 1:200 AVENUE F NORTHEAST
Mailing Address - Street 2:CANCER CTR
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33881
Mailing Address - Country:US
Mailing Address - Phone:863-292-4670
Mailing Address - Fax:863-292-4671
Practice Address - Street 1:200 AVENUE F NE
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33881-4131
Practice Address - Country:US
Practice Address - Phone:863-292-4670
Practice Address - Fax:863-292-4671
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 103579207R00000X, 207RH0003X
NC2013-00226207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNC2239Medicaid
NC180AAOtherBCBS NC
NC1306938774Medicaid
NCNCC250DMedicare PIN
NCNCC250AMedicare PIN
SCNC2239Medicaid
NCNCC250BMedicare PIN