Provider Demographics
NPI:1821025743
Name:HANSON, CLARENCE W III (MD)
Entity Type:Individual
Prefix:
First Name:CLARENCE
Middle Name:W
Last Name:HANSON
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:C
Other - Middle Name:W
Other - Last Name:HANSON
Other - Suffix:III
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:3400 SPRUCE STREET
Mailing Address - Street 2:4 DULLES
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-4206
Mailing Address - Country:US
Mailing Address - Phone:215-349-8310
Mailing Address - Fax:
Practice Address - Street 1:3400 SPRUCE STREET
Practice Address - Street 2:4 DULLES
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-4206
Practice Address - Country:US
Practice Address - Phone:215-349-8310
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2012-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD043548E207L00000X, 207LC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LC0200XAllopathic & Osteopathic PhysiciansAnesthesiologyCritical Care Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001901150002Medicaid
PA001901150002Medicaid
PA593133EUYMedicare PIN
PA593133GWKMedicare PIN