Provider Demographics
NPI:1205063476
Name:HANLEY, EUGERIE ALTAGRACE (MD)
Entity type:Individual
Prefix:
First Name:EUGERIE
Middle Name:ALTAGRACE
Last Name:HANLEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:EUGERIE
Other - Middle Name:ALTAGRACE
Other - Last Name:DOUGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 1608
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72702-1608
Mailing Address - Country:US
Mailing Address - Phone:479-521-2752
Mailing Address - Fax:479-521-4603
Practice Address - Street 1:444 FOUR STATES DR STE 1
Practice Address - Street 2:
Practice Address - City:GALENA
Practice Address - State:KS
Practice Address - Zip Code:66739-4325
Practice Address - Country:US
Practice Address - Phone:620-783-4441
Practice Address - Fax:620-783-4090
Is Sole Proprietor?:No
Enumeration Date:2009-06-16
Last Update Date:2019-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0441896208100000X
ARE-9087208100000X, 208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5BF01OtherBLUE CROSS
AR210206001Medicaid
AR210206001Medicaid
MNENROLLEDMedicaid