Healthcare Provider Details

I. General information

NPI: 1720078629
Provider Name (Legal Business Name): HISHAM T YOUSSEF MD RADIOLOGIST
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2005
Last Update Date: 04/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 E CLARK ST
HARRISBURG IL
62946-2703
US

IV. Provider business mailing address

112 E CLARK ST PO BOX 265
HARRISBURG IL
62946-2703
US

V. Phone/Fax

Practice location:
  • Phone: 618-252-8337
  • Fax: 618-252-8338
Mailing address:
  • Phone: 618-926-5808
  • Fax: 618-252-8338

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number336-051265 036089504
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: