1508835794 NPI number — BRETT W. HANNA

Table of content: (NPI 1508835794)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508835794 NPI number — BRETT W. HANNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRETT W. HANNA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1508835794
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/22/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2177
Provider Second Line Business Mailing Address:
110 E. BRANTLEY, STE. 6
Provider Business Mailing Address City Name:
TRINITY
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75862-2177
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
936-594-5460
Provider Business Mailing Address Fax Number:
936-594-9082

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
110 E BRANTLEY RD STE 6
Provider Second Line Business Practice Location Address:
BOX 2177
Provider Business Practice Location Address City Name:
TRINITY
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75862-2177
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
936-594-5460
Provider Business Practice Location Address Fax Number:
936-594-9082
Provider Enumeration Date:
03/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HANNA
Authorized Official First Name:
SHELLY
Authorized Official Middle Name:
Authorized Official Title or Position:
BILLING
Authorized Official Telephone Number:
936-594-5460

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 011023101 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 016993001 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 530548 . This is a "BLUE CROSS BLUE SHIELD TX" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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