Provider Demographics
NPI:1679549356
Name:HASAN, SIDDIQ S (MD)
Entity Type:Individual
Prefix:
First Name:SIDDIQ
Middle Name:S
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 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:9800 VALPARAISO DR
Practice Address - Street 2:
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-4040
Practice Address - Country:US
Practice Address - Phone:219-934-9852
Practice Address - Fax:219-836-7593
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-23
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036111304208600000X
IN01087941A208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL9930030OtherBCBS OF ILLINOIS
IL9930030OtherBCBS OF ILLINOIS
I23256Medicare UPIN
ILK13592Medicare ID - Type UnspecifiedLOC 16
K13591Medicare ID - Type UnspecifiedLOC 15