Provider Demographics
NPI:1407812050
Name:KIESO, HASSAN
Entity Type:Individual
Prefix:
First Name:HASSAN
Middle Name:
Last Name:KIESO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1040 SIERRA DRIVE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46143-7241
Mailing Address - Country:US
Mailing Address - Phone:317-528-4253
Mailing Address - Fax:317-865-8319
Practice Address - Street 1:3800 W 203RD ST
Practice Address - Street 2:SUITE 204
Practice Address - City:OLYMPIA FIELDS
Practice Address - State:IL
Practice Address - Zip Code:60461-1184
Practice Address - Country:US
Practice Address - Phone:708-679-2670
Practice Address - Fax:708-503-3260
Is Sole Proprietor?:No
Enumeration Date:2006-04-24
Last Update Date:2020-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036092223207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036092223Medicaid
ILL95559OtherMEDICARE PTAN
G99671Medicare UPIN
G99671Medicare UPIN