Healthcare Provider Details

I. General information

NPI: 1801467295
Provider Name (Legal Business Name): WAHEED UL HASSAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2021
Last Update Date: 01/03/2025
Certification Date: 01/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1505 EASTLAND DR
BLOOMINGTON IL
61701-3534
US

IV. Provider business mailing address

G3230 BEECHER RD STE 2
FLINT MI
48532-3604
US

V. Phone/Fax

Practice location:
  • Phone: 309-662-3311
  • Fax: 309-662-9709
Mailing address:
  • Phone: 810-342-5800
  • Fax: 810-342-5810

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number4351047784
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036170960
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: