Provider Demographics
NPI:1568417301
Name:HASSAN, JOHARA ADAM (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHARA
Middle Name:ADAM
Last Name:HASSAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:GAWHARA
Other - Middle Name:
Other - Last Name:HASSAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:820 S WOOD ST
Mailing Address - Street 2:SUITE 172 (MC 712)
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-4325
Mailing Address - Country:US
Mailing Address - Phone:312-996-5680
Mailing Address - Fax:312-996-5984
Practice Address - Street 1:801 5TH ST
Practice Address - Street 2:
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51101-1326
Practice Address - Country:US
Practice Address - Phone:712-279-2010
Practice Address - Fax:712-279-2034
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020039485208M00000X, 207R00000X
IL036109970208M00000X, 207R00000X
IAMD-44833207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036109970OtherPROFESSIONAL LICENSE
IL036109970Medicaid
IL336072134OtherCONTROLLED SUBSTANCE
IL336072134OtherCONTROLLED SUBSTANCE
ILK22045Medicare PIN
IL536800Medicare ID - Type UnspecifiedGALILEE GROUP
IL036109970Medicaid
ILBH8902997OtherDEA