Healthcare Provider Details

I. General information

NPI: 1184357451
Provider Name (Legal Business Name): HASAN DIAB HASAN SQOUR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2022
Last Update Date: 07/05/2022
Certification Date: 07/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 N LAKE SHORE DR STE 204
CHICAGO IL
60657-5640
US

IV. Provider business mailing address

420 W WRIGHTWOOD AVE APT 227
CHICAGO IL
60614-2899
US

V. Phone/Fax

Practice location:
  • Phone: 773-665-3017
  • Fax:
Mailing address:
  • Phone: 224-336-0285
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number125079984
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: