Provider Demographics
NPI:1962661736
Name:MID AMERICA NEUROSPINE LLC
Entity Type:Organization
Organization Name:MID AMERICA NEUROSPINE LLC
Other - Org Name:E JEROME HANSON MD
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:ERNEST
Authorized Official - Middle Name:JEROME
Authorized Official - Last Name:HANSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:913-851-2919
Mailing Address - Street 1:15438 IRON HORSE CIR
Mailing Address - Street 2:
Mailing Address - City:LEAWOOD
Mailing Address - State:KS
Mailing Address - Zip Code:66224-3852
Mailing Address - Country:US
Mailing Address - Phone:913-851-2919
Mailing Address - Fax:
Practice Address - Street 1:5701 W 119TH ST
Practice Address - Street 2:SUITE 331
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66209-3721
Practice Address - Country:US
Practice Address - Phone:913-851-2919
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-05
Last Update Date:2008-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-16128174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
060060027OtherMEDICARE RAILROAD #
27321011OtherGROUP BCBS#
02119079OtherBCBS
KSP163279OtherMEDICARE INDIVIDUAL P163279
D17381Medicare UPIN
02119079OtherBCBS