Provider Demographics
NPI:1265480628
Name:HANNA, STEPHAN D (MD)
Entity Type:Individual
Prefix:
First Name:STEPHAN
Middle Name:D
Last Name:HANNA
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:RR 1 BOX 256
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:26181-9708
Mailing Address - Country:US
Mailing Address - Phone:304-863-3373
Mailing Address - Fax:
Practice Address - Street 1:1907 ANN ST
Practice Address - Street 2:
Practice Address - City:PARKERSBURG
Practice Address - State:WV
Practice Address - Zip Code:26101-2504
Practice Address - Country:US
Practice Address - Phone:304-424-4205
Practice Address - Fax:304-424-4485
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2010-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV13524207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
000034367OtherBLUE CROSS/BLUE SHIELD
080094477OtherRAILROAD MEDICARE
OH0541186Medicaid
WV0056732000Medicaid
HA0534172Medicare ID - Type Unspecified
A72248Medicare UPIN