Basic Information
Provider Information | |||||||||
NPI: | 1295734135 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HANSON | ||||||||
FirstName: | KENNETH | ||||||||
MiddleName: | C. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: | JR. | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 7905 E CURTIS RD | ||||||||
Address2: |   | ||||||||
City: | FRANKENMUTH | ||||||||
State: | MI | ||||||||
PostalCode: | 487349583 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: | 2622452248 | ||||||||
Practice Location | |||||||||
Address1: | 900 COOPER AVE | ||||||||
Address2: |   | ||||||||
City: | SAGINAW | ||||||||
State: | MI | ||||||||
PostalCode: | 486025182 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9895836521 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/20/2005 | ||||||||
LastUpdateDate: | 03/26/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/26/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 01054195A | IN | N |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   | 207PE0004X | 036-141304 | IL | N |   | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services | 207PE0004X | 65793-20 | WI | Y |   | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services |
ID Information
ID | Type | State | Issuer | Description | HANSOKEN | 01 | WI | MERCYCARE INSURANCE | OTHER | 000000198747 | 01 | IN | BLUE CROSS/BLUE SHIELD | OTHER | 000000640498 | 01 | IN | BC/BS | OTHER | 1295734135 | 05 | WI |   | MEDICAID | P00775286 | 01 | IN | RAILROAD MEDICARE | OTHER | 000000668240 | 01 | IN | ANTHEM BC/BS | OTHER | 200336440A | 05 | IN |   | MEDICAID | P00023838 | 01 | IN | RAIL ROAD | OTHER | P00841040 | 01 | IN | RAILROAD MEDICARE | OTHER | 1295734135 | 01 | WI | BCBSWI | OTHER |