Provider Demographics
NPI:1225051428
Name:HANNA, ISIS A (MD)
Entity Type:Individual
Prefix:
First Name:ISIS
Middle Name:A
Last Name:HANNA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22745 KELLY RD
Mailing Address - Street 2:
Mailing Address - City:EASTPOINTE
Mailing Address - State:MI
Mailing Address - Zip Code:48021
Mailing Address - Country:US
Mailing Address - Phone:586-771-1000
Mailing Address - Fax:586-779-0058
Practice Address - Street 1:22745 KELLY RD
Practice Address - Street 2:
Practice Address - City:EASTPOINTE
Practice Address - State:MI
Practice Address - Zip Code:48021
Practice Address - Country:US
Practice Address - Phone:586-771-1000
Practice Address - Fax:586-779-0058
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2009-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301032360207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI101770044Medicaid
D91443Medicare UPIN
MI101770044Medicaid