Healthcare Provider Details

I. General information

NPI: 1154736452
Provider Name (Legal Business Name): SUMMER MUSTAFA HASSAN D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2014
Last Update Date: 06/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 FRANKLIN AVE SUITE #110
NORMAL IL
61761-3592
US

IV. Provider business mailing address

1300 FRANKLIN AVE SUITE #110
NORMAL IL
61761-3592
US

V. Phone/Fax

Practice location:
  • Phone: 309-268-3502
  • Fax: 309-268-3713
Mailing address:
  • Phone: 309-268-3502
  • Fax: 309-268-3713

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number125065755
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: