Healthcare Provider Details

I. General information

NPI: 1043415755
Provider Name (Legal Business Name): IHAB O ELHASSAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2007
Last Update Date: 07/27/2021
Certification Date: 07/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3533 SOUTHERN BLVD STE 2100
KETTERING OH
45429-1267
US

IV. Provider business mailing address

1 PRESTIGE PL STE 550
MIAMISBURG OH
45342-6115
US

V. Phone/Fax

Practice location:
  • Phone: 937-395-8556
  • Fax: 937-395-6376
Mailing address:
  • Phone: 937-762-1310
  • Fax: 937-522-8068

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number35126492
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License Number35126492
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: