Provider Demographics
NPI:1023088978
Name:HASSAN, IMRAN (MD)
Entity type:Individual
Prefix:
First Name:IMRAN
Middle Name:
Last Name:HASSAN
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 19638
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62794-9638
Mailing Address - Country:US
Mailing Address - Phone:217-545-1025
Mailing Address - Fax:217-545-0952
Practice Address - Street 1:315 W CARPENTER ST
Practice Address - Street 2:2 ND FLOOR
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-4901
Practice Address - Country:US
Practice Address - Phone:217-545-1025
Practice Address - Fax:217-545-0952
Is Sole Proprietor?:No
Enumeration Date:2006-01-24
Last Update Date:2012-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN41912208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036116661Medicaid
MN333677800Medicaid
MN020044188Medicare ID - Type UnspecifiedRAILROAD
MN280000109Medicare ID - Type Unspecified
H06397Medicare UPIN