Healthcare Provider Details

I. General information

NPI: 1972839041
Provider Name (Legal Business Name): BURHAN HASSAN M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2009
Last Update Date: 06/28/2023
Certification Date: 06/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8600 N STATE ROUTE 91
PEORIA IL
61615-9541
US

IV. Provider business mailing address

8600 N STATE ROUTE 91
PEORIA IL
61615-9541
US

V. Phone/Fax

Practice location:
  • Phone: 309-691-4005
  • Fax: 309-691-6144
Mailing address:
  • Phone: 309-691-4005
  • Fax: 309-691-6144

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number32216
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number036156935
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: