Healthcare Provider Details

I. General information

NPI: 1992200489
Provider Name (Legal Business Name): RUWAYDAH HASAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2018
Last Update Date: 12/28/2023
Certification Date: 12/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1777 NORTHEAST EXPY NE
BROOKHAVEN GA
30329-2480
US

IV. Provider business mailing address

1777 NORTHEAST EXPY NE
BROOKHAVEN GA
30329-2480
US

V. Phone/Fax

Practice location:
  • Phone: 404-785-5437
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number95713
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number95713
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: