Provider Demographics
NPI:1023083748
Name:HANSON, EMILY D (DO)
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:D
Last Name:HANSON
Suffix:
Gender:F
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:PO BOX 3988
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62902-3988
Mailing Address - Country:US
Mailing Address - Phone:618-457-5200
Mailing Address - Fax:
Practice Address - Street 1:19 E SHAWNEE DR STE 2
Practice Address - Street 2:
Practice Address - City:MURPHYSBORO
Practice Address - State:IL
Practice Address - Zip Code:62966-7072
Practice Address - Country:US
Practice Address - Phone:618-684-2172
Practice Address - Fax:618-687-4480
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036107935207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL7210895OtherAETNA
IL036107935Medicaid
IL3932056OtherBCBS
IL206302Medicare ID - Type Unspecified
IL214881Medicare Oscar/Certification
IL214881079Medicare PIN
H88897Medicare UPIN