Provider Demographics
NPI:1952627523
Name:HANSEN, ERIC S (DO)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:S
Last Name:HANSEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12410 MILESTONE CENTER DR
Mailing Address - Street 2:SUITE 225
Mailing Address - City:GERMANTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:20876-7101
Mailing Address - Country:US
Mailing Address - Phone:800-828-0898
Mailing Address - Fax:
Practice Address - Street 1:12500 WILLOWBROOK RD
Practice Address - Street 2:
Practice Address - City:CUMBERLAND
Practice Address - State:MD
Practice Address - Zip Code:21502-6393
Practice Address - Country:US
Practice Address - Phone:240-964-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-07
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI57287-21207P00000X
MDH77833207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI686550197Medicare PIN
WI014000185Medicare PIN