Provider Demographics
NPI:1730292798
Name:HANSON, BURNETT (MD)
Entity Type:Individual
Prefix:
First Name:BURNETT
Middle Name:
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:DEPT 1871
Mailing Address - Street 2:PO BOX 2153
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35287-1871
Mailing Address - Country:US
Mailing Address - Phone:770-429-1411
Mailing Address - Fax:770-429-1951
Practice Address - Street 1:1501 ASTON AVE
Practice Address - Street 2:
Practice Address - City:MCCOMB
Practice Address - State:MS
Practice Address - Zip Code:39648-2734
Practice Address - Country:US
Practice Address - Phone:601-249-5510
Practice Address - Fax:601-249-5530
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2012-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS183482085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02984324Medicaid
5574657OtherAETNA
MSP00086160OtherRAILROAD MEDICARE
MS02984324Medicaid
$$$$$$$$$OtherCHAMPUS
MS02984324Medicaid
C03050Medicare PIN