1033398300 NPI number — HEATH HANSEN

Table of content: HEATH HANSEN (NPI 1033398300)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033398300 NPI number — HEATH HANSEN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HANSEN
Provider First Name:
HEATH
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1033398300
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/23/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12400 S HARLEM AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PALOS HEIGHTS
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60463-1440
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9009B INDIANAPOLIS BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HIGHLAND
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46322-2502
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
219-923-0454
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/02/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225500000X , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 225400000X , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 01622333 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 7454077 . This is a "AETNA" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 01622333 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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