Provider Demographics
NPI:1225000367
Name:HANSEN, ROGER G (MD)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:G
Last Name:HANSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 751803
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1803
Mailing Address - Country:US
Mailing Address - Phone:336-774-0040
Mailing Address - Fax:336-774-0029
Practice Address - Street 1:600 HIGHLAND OAKS DR
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-7107
Practice Address - Country:US
Practice Address - Phone:336-774-0040
Practice Address - Fax:336-774-0029
Is Sole Proprietor?:No
Enumeration Date:2006-02-03
Last Update Date:2013-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC36359207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8939081Medicaid
NC2182658CMedicare ID - Type Unspecified
NCF49496Medicare UPIN
NCNC2317BMedicare PIN