Healthcare Provider Details

I. General information

NPI: 1720278708
Provider Name (Legal Business Name): HASSAN ISSA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2007
Last Update Date: 03/01/2022
Certification Date: 03/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31 FARQUHAR AVE
WILMINGTON OH
45177-2188
US

IV. Provider business mailing address

200 N PARK ST
KALAMAZOO MI
49007-3731
US

V. Phone/Fax

Practice location:
  • Phone: 937-283-2273
  • Fax: 937-283-2278
Mailing address:
  • Phone: 269-373-7488
  • Fax: 269-373-7478

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number2015013477
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number4301097673
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: