Provider Demographics
NPI:1265602833
Name:HASSELMARK, FAIROUZ NOURI (MD)
Entity type:Individual
Prefix:DR
First Name:FAIROUZ
Middle Name:NOURI
Last Name:HASSELMARK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:FAIROUZ
Other - Middle Name:NOURI
Other - Last Name:AL-OTHMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1351 ROUTE 55
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LAGRANGEVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12540-5108
Mailing Address - Country:US
Mailing Address - Phone:845-475-9660
Mailing Address - Fax:845-475-9938
Practice Address - Street 1:45 READE PL
Practice Address - Street 2:
Practice Address - City:POUGHKEEPSIE
Practice Address - State:NY
Practice Address - Zip Code:12601-3947
Practice Address - Country:US
Practice Address - Phone:845-454-8500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-10
Last Update Date:2017-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY249042207R00000X, 207RP1001X, 207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03503317Medicaid
NY03503317Medicaid