Healthcare Provider Details

I. General information

NPI: 1205271632
Provider Name (Legal Business Name): AYESHA HASAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2013
Last Update Date: 07/17/2020
Certification Date: 07/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 W TAYLOR ST # MC650
CHICAGO IL
60612-4795
US

IV. Provider business mailing address

820 S WOOD ST # MC808
CHICAGO IL
60612-4325
US

V. Phone/Fax

Practice location:
  • Phone: 312-413-7500
  • Fax: 312-413-3856
Mailing address:
  • Phone: 312-996-7300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VM0101X
TaxonomyMaternal & Fetal Medicine Physician
License Number036152894
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: