Healthcare Provider Details

I. General information

NPI: 1427150168
Provider Name (Legal Business Name): KAMAL S HASAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2006
Last Update Date: 09/20/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1260 N IRISH RD SUITE A
DAVISON MI
48423-2213
US

IV. Provider business mailing address

3495 S CENTER RD
BURTON MI
48519-1455
US

V. Phone/Fax

Practice location:
  • Phone: 810-658-9550
  • Fax: 810-658-2202
Mailing address:
  • Phone: 810-424-2007
  • Fax: 810-743-1099

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301063221
License Number StateMI

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier4667501
Identifier TypeMEDICAID
Identifier StateMI
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: