Healthcare Provider Details

I. General information

NPI: 1487779922
Provider Name (Legal Business Name): JEAN-MICHEL, HASSAN, MD SOUTHWEST CLINIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/21/2007
Last Update Date: 02/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 W 15TH ST STE D
LIBERAL KS
67901-2468
US

IV. Provider business mailing address

555 W 15TH ST STE D
LIBERAL KS
67901-2468
US

V. Phone/Fax

Practice location:
  • Phone: 620-626-4368
  • Fax: 620-626-7370
Mailing address:
  • Phone: 620-626-4368
  • Fax: 620-626-7370

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0007X
TaxonomyPlastic Surgery within the Head & Neck (Otolaryngology) Physician
License Number0431410
License Number StateKS

VIII. Authorized Official

Name: DR. JEAN MICHEL HASSAN
Title or Position: PHYSICIAN OWNER
Credential: MD
Phone: 620-626-4368