Basic Information
| Provider Information | |||||||||
| NPI: | 1992891444 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HANSEN | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 RIVER ROAD | ||||||||
| Address2: | STE 100 | ||||||||
| City: | CONSHOHOCKEN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 19428 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003553818 | ||||||||
| FaxNumber: | 6108342862 | ||||||||
| Practice Location | |||||||||
| Address1: | 9000 FRANKLIN SQUARE | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 21218 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2028779696 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2006 | ||||||||
| LastUpdateDate: | 02/29/2008 | ||||||||
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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 | 207P00000X | D61662 | MD | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 75859901 | 01 | MD | BLUE SHIELD | OTHER | P00158935 | 01 | MD | RAILROAD MED | OTHER |