Provider Demographics
NPI:1790149219
Name:MARLAN HANSEN MD LLC
Entity Type:Organization
Organization Name:MARLAN HANSEN MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER RELATIONS
Authorized Official - Prefix:
Authorized Official - First Name:KAILEE
Authorized Official - Middle Name:
Authorized Official - Last Name:GORES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-352-9500
Mailing Address - Street 1:PO BOX 95590
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-0590
Mailing Address - Country:US
Mailing Address - Phone:801-352-9500
Mailing Address - Fax:801-352-7976
Practice Address - Street 1:538 S 500 E
Practice Address - Street 2:
Practice Address - City:AMERICAN FORK
Practice Address - State:UT
Practice Address - Zip Code:84003-2676
Practice Address - Country:US
Practice Address - Phone:801-642-2000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-11
Last Update Date:2016-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT327162-1205207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty