Basic Information
| Provider Information | |||||||||
| NPI: | 1619909991 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HASAN | ||||||||
| FirstName: | SYED | ||||||||
| MiddleName: | MAHMOOD | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6626 E 75TH STREET | ||||||||
| Address2: | SUITE 500 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462502890 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3176217561 | ||||||||
| FaxNumber: | 3173556096 | ||||||||
| Practice Location | |||||||||
| Address1: | 7165 CLEARVISTA WAY | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462564621 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3176215100 | ||||||||
| FaxNumber: | 3176217896 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2006 | ||||||||
| LastUpdateDate: | 10/03/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 01057120A | IN | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 000000653878 | 01 | IN | ANTHEM | OTHER | 71255583 | 05 | NM | MEDICAID | P01191764 | 01 | IN | RR MEDICARE PTAN | OTHER | 000000721882 | 01 | IN | ANTHEM | OTHER | 244724 | 01 | IN | VALUE OPTIONS | OTHER | 200858960 | 05 | IN | MEDICAID | 284745 | 01 | IN | MANAGED HEALTH NETWORK | OTHER | 000000983429 | 01 | IN | ANTHEM PIN | OTHER |