Healthcare Provider Details

I. General information

NPI: 1407944192
Provider Name (Legal Business Name): SOUTHERN ILLINOIS VASCULAR SURGERY, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 W LINCOLN ST SUITE 200
BELLEVILLE IL
62220-1902
US

IV. Provider business mailing address

311 W LINCOLN ST SUITE 200
BELLEVILLE IL
62220-1902
US

V. Phone/Fax

Practice location:
  • Phone: 618-233-2500
  • Fax: 618-233-2520
Mailing address:
  • Phone: 618-233-2500
  • Fax: 618-233-2520

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number StateIL

VIII. Authorized Official

Name: DR. HANS HASSAN MOOSA
Title or Position: PRESIDENT
Credential: M.D.
Phone: 618-233-2500