Provider Demographics
NPI:1023993862
Name:HEJAH, BASSAM MO
Entity type:Individual
Prefix:
First Name:BASSAM
Middle Name:MO
Last Name:HEJAH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1109 MIDDLETON ST
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53717-1078
Mailing Address - Country:US
Mailing Address - Phone:608-405-2205
Mailing Address - Fax:
Practice Address - Street 1:1109 MIDDLETON ST
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53717-1078
Practice Address - Country:US
Practice Address - Phone:608-405-2205
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-11
Last Update Date:2025-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes167G00000XNursing Service ProvidersLicensed Psychiatric TechnicianGroup - Multi-Specialty