Provider Demographics
NPI:1063510014
Name:RADWAN, HOSSAM (MD)
Entity Type:Individual
Prefix:
First Name:HOSSAM
Middle Name:
Last Name:RADWAN
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 1:23 GEMINI LN
Mailing Address - Street 2:
Mailing Address - City:MANALAPAN
Mailing Address - State:NJ
Mailing Address - Zip Code:07726-8816
Mailing Address - Country:US
Mailing Address - Phone:732-863-1118
Mailing Address - Fax:
Practice Address - Street 1:511 NEW BRUNSWICK AVE
Practice Address - Street 2:
Practice Address - City:PERTH AMBOY
Practice Address - State:NJ
Practice Address - Zip Code:08861-3682
Practice Address - Country:US
Practice Address - Phone:732-442-0300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2014-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA06340100207P00000X
NJMA 63401208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
767940Medicare PIN