Healthcare Provider Details

I. General information

NPI: 1780481234
Provider Name (Legal Business Name): HOSSAM FATHI HALAWEISH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/03/2025
Last Update Date: 06/23/2026
Certification Date: 06/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 DELAWARE ST SE
MINNEAPOLIS MN
55455-0341
US

IV. Provider business mailing address

8057 GARFIELD ST NE
SPRING LAKE PARK MN
55432-2164
US

V. Phone/Fax

Practice location:
  • Phone: 612-626-2935
  • Fax:
Mailing address:
  • Phone: 605-633-8176
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number125.088413
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: