Provider Demographics
NPI:1225140437
Name:HANSON, KENNETH CHARLES (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:CHARLES
Last Name:HANSON
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 1:802 W KING ST
Mailing Address - Street 2:STE Q
Mailing Address - City:OWOSSO
Mailing Address - State:MI
Mailing Address - Zip Code:48867
Mailing Address - Country:US
Mailing Address - Phone:989-723-7619
Mailing Address - Fax:989-723-0090
Practice Address - Street 1:802 W KING ST
Practice Address - Street 2:STE Q
Practice Address - City:OWOSSO
Practice Address - State:MI
Practice Address - Zip Code:48867
Practice Address - Country:US
Practice Address - Phone:989-723-7619
Practice Address - Fax:989-723-0090
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301027519207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1097184Medicaid
MI1007800511OtherBCBS OF MICHIGAN
B44629Medicare UPIN
MI1007800511OtherBCBS OF MICHIGAN