Basic Information
| Provider Information | |||||||||
| NPI: | 1255580031 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | REDA | ||||||||
| FirstName: | HAATEM | ||||||||
| MiddleName: | MOSTAFA | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 55 FRUIT STREET | ||||||||
| Address2: | MASSACHUSETTS GENERAL HOSPITAL | ||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021142621 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6177262000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 55 FRUIT STREET | ||||||||
| Address2: | MASSACHUSETTS GENERAL HOSPITAL | ||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021142621 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6177262000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2008 | ||||||||
| LastUpdateDate: | 02/15/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 104544 | MN | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0400X | 52343 | MN | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | ENROLLED | 05 | MN | MEDICAID |