Provider Demographics
NPI:1740301456
Name:HASSANEIN CLINIC INC
Entity type:Organization
Organization Name:HASSANEIN CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HOSSAM
Authorized Official - Middle Name:M
Authorized Official - Last Name:HASSANEIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:772-323-2461
Mailing Address - Street 1:437 NW PRIMA VISTA BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34983-8731
Mailing Address - Country:US
Mailing Address - Phone:772-323-2461
Mailing Address - Fax:772-323-2462
Practice Address - Street 1:437 NW PRIMA VISTA BLVD
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34983-8731
Practice Address - Country:US
Practice Address - Phone:772-323-2461
Practice Address - Fax:772-323-2462
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-02
Last Update Date:2007-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME68679261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL28313VMedicare ID - Type Unspecified
FLF00421Medicare UPIN