MEDICARE: DR. HASSAN TAKI M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	01042585	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1924	OTHER	IN	PHYSCIANS HEALTH PLAN
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	1659549475	OTHER		GROUP NPI
4	000000091432	OTHER	IN	BLUE CROSS/BLUE SHIELD

General Provider Information

NPI Number	:	1114911807
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. HASSAN TAKI M.D.

Provider Business Mailing Address
First Line	:	4424 E STATE BLVD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46815-6917
Country	:	US
Telephone Number	:	260-483-4433
Fax Number	:	260-483-4223

Provider Business Practice Location Address
First Line	:	4424 E STATE BLVD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46815-6917
Country	:	US
Telephone Number	:	260-483-4433
Fax Number	:	260-483-4223

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/08/2005
Last Update Date	:	07/26/2022

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