Provider Demographics
NPI:1053324962
Name:KASSAMALI, HASSAN (MD)
Entity type:Individual
Prefix:
First Name:HASSAN
Middle Name:
Last Name:KASSAMALI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 FONTANA LN
Mailing Address - Street 2:SUITE 101 & 103
Mailing Address - City:ROSEDALE
Mailing Address - State:MD
Mailing Address - Zip Code:21237-3042
Mailing Address - Country:US
Mailing Address - Phone:410-687-0000
Mailing Address - Fax:410-391-8656
Practice Address - Street 1:17 FONTANA LN
Practice Address - Street 2:SUITE 101
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21237-3042
Practice Address - Country:US
Practice Address - Phone:410-687-0000
Practice Address - Fax:410-391-8656
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2013-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0046126174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD523801300Medicaid
MDE94328Medicare UPIN
MD394QMedicare ID - Type Unspecified