Basic Information
Provider Information | |||||||||
NPI: | 1891080883 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HASAN | ||||||||
FirstName: | SYED | ||||||||
MiddleName: | MUSTAFA | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | HASAN | ||||||||
OtherFirstName: | MUSTAFA | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.D. | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | 300 S BRUCE ST | ||||||||
Address2: | AVERA MARSHALL | ||||||||
City: | MARSHALL | ||||||||
State: | MN | ||||||||
PostalCode: | 562581934 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5075379300 | ||||||||
FaxNumber: | 5075379356 | ||||||||
Practice Location | |||||||||
Address1: | 1100 MERCER AVE | ||||||||
Address2: |   | ||||||||
City: | DECATUR | ||||||||
State: | IN | ||||||||
PostalCode: | 467332303 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2607242145 | ||||||||
FaxNumber: | 2607283852 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/17/2011 | ||||||||
LastUpdateDate: | 03/29/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/29/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 58354 | MN | N |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   | 207Q00000X | 01072973A | IN | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 207P00000X | 01072973A | IN | Y |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   |
No ID Information.