Basic Information
| Provider Information | |||||||||
| NPI: | 1033398300 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | HANSEN | ||||||||
| FirstName: | HEATH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12400 S HARLEM AVE | ||||||||
| Address2: | |||||||||
| City: | PALOS HEIGHTS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604631440 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 9009B INDIANAPOLIS BLVD | ||||||||
| Address2: | |||||||||
| City: | HIGHLAND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463222502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2199230454 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2007 | ||||||||
| LastUpdateDate: | 11/23/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225500000X | IN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | 225400000X | IN | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 01622333 | 01 | IL | BLUE CROSS BLUE SHIELD | OTHER | 7454077 | 01 | IN | AETNA | OTHER | 01622333 | 01 | IN | BLUE CROSS BLUE SHIELD | OTHER |