Provider Demographics
NPI:1023212289
Name:ELGHANNAM, HESHAM M (MD)
Entity Type:Individual
Prefix:DR
First Name:HESHAM
Middle Name:M
Last Name:ELGHANNAM
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 1:2424 S 90TH ST STE 300
Mailing Address - Street 2:
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53227-2455
Mailing Address - Country:US
Mailing Address - Phone:414-328-8150
Mailing Address - Fax:
Practice Address - Street 1:2424 S 90TH ST STE 300
Practice Address - Street 2:
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53227-2455
Practice Address - Country:US
Practice Address - Phone:414-328-8150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-12
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI61317207RP1001X, 207RP1001X
WAMD00048849207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100033017Medicaid
WA0235677OtherWA STATE LABOR & INDUSTRIES
WA8509416Medicaid
CAW809BMedicare ID - Type UnspecifiedHUDSON
CAW932Medicare ID - Type UnspecifiedHEALTH CENTERS
WA8509416Medicaid