Basic Information
Provider Information | |||||||||
NPI: | 1770674418 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HANGEN | ||||||||
FirstName: | ELLEN | ||||||||
MiddleName: | M | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 154 | ||||||||
Address2: |   | ||||||||
City: | CHASE | ||||||||
State: | MD | ||||||||
PostalCode: | 210270154 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4103350159 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 4337 EBENEZER RD | ||||||||
Address2: |   | ||||||||
City: | NOTTINGHAM | ||||||||
State: | MD | ||||||||
PostalCode: | 212362143 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4105293303 | ||||||||
FaxNumber: | 4105297980 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/27/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 20700 | MD | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
ID Information
ID | Type | State | Issuer | Description | 60312 | 01 | MD | OPTIMUM CHOICE/MAMSI | OTHER | 61770302 | 01 | MD | CAREFIRST OF MD | OTHER | F5170008 | 01 | MD | GHMSI | OTHER | P00231190 | 01 | MD | RAILROAD MEDICARE | OTHER |