Basic Information
| Provider Information | |||||||||
| NPI: | 1841252038 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HANSEN | ||||||||
| FirstName: | HERBERT | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 4 PALISADES DR | ||||||||
| Address2: | STE 200 | ||||||||
| City: | ALBANY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 122051443 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5185256418 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 205 E BROWN ST | ||||||||
| Address2: | |||||||||
| City: | EAST STROUDSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 183013006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5704202188 | ||||||||
| FaxNumber: | 5704213493 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2006 | ||||||||
| LastUpdateDate: | 06/23/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | MD449121 | PA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | 207RX0202X | 122972 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology | 207RH0003X | 58489 | MA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 3029930 | 05 | MA | MEDICAID |