Provider Demographics
NPI:1619038213
Name:GARY A HANSON MD INC
Entity Type:Organization
Organization Name:GARY A HANSON MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:A
Authorized Official - Last Name:HANSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-723-0200
Mailing Address - Street 1:2619 PENNSYLVANIA AVE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:WEIRTON
Mailing Address - State:WV
Mailing Address - Zip Code:26062-3752
Mailing Address - Country:US
Mailing Address - Phone:304-723-0200
Mailing Address - Fax:304-723-0210
Practice Address - Street 1:2619 PENNSYLVANIA AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:WEIRTON
Practice Address - State:WV
Practice Address - Zip Code:26062-3752
Practice Address - Country:US
Practice Address - Phone:304-723-0200
Practice Address - Fax:304-723-0210
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2010-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV12678174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0071764000Medicaid
WV0071764000Medicaid
WVA72138Medicare UPIN