Provider Demographics
NPI:1861490260
Name:HANSEN, REID H (MD)
Entity Type:Individual
Prefix:DR
First Name:REID
Middle Name:H
Last Name:HANSEN
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 1:900 MAIN ST
Mailing Address - Street 2:SUITE 500
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61602-1005
Mailing Address - Country:US
Mailing Address - Phone:309-637-3500
Mailing Address - Fax:309-637-3507
Practice Address - Street 1:900 MAIN ST
Practice Address - Street 2:SUITE 500
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61602-1005
Practice Address - Country:US
Practice Address - Phone:309-637-3500
Practice Address - Fax:309-637-3507
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-09
Last Update Date:2009-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-064366208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
D14903Medicare UPIN
687-801Medicare ID - Type Unspecified