Provider Demographics
NPI:1326024134
Name:HASAN, NIDAL (MD)
Entity Type:Individual
Prefix:
First Name:NIDAL
Middle Name:
Last Name:HASAN
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:PO BOX 1200
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60462-8200
Mailing Address - Country:US
Mailing Address - Phone:773-820-0928
Mailing Address - Fax:
Practice Address - Street 1:1747 E 87TH ST
Practice Address - Street 2:B-390
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60617-2741
Practice Address - Country:US
Practice Address - Phone:773-978-4330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2021-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036091656207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01621679OtherBCBS OF IL
IL036091656Medicaid
ILK09002Medicare ID - Type UnspecifiedGROUP 950150
IL036091656Medicaid