Provider Demographics
NPI:1205072923
Name:STEPHEN M HANSEN MD PC
Entity type:Organization
Organization Name:STEPHEN M HANSEN MD PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:M
Authorized Official - Last Name:HANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:435-656-0234
Mailing Address - Street 1:619 S BLUFF ST
Mailing Address - Street 2:TOWER 1 SUITE 100
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84770-3853
Mailing Address - Country:US
Mailing Address - Phone:435-656-0234
Mailing Address - Fax:435-656-2622
Practice Address - Street 1:619 S BLUFF ST
Practice Address - Street 2:TOWER 1 SUITE 100
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84770-3853
Practice Address - Country:US
Practice Address - Phone:435-656-0234
Practice Address - Fax:435-656-2622
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-30
Last Update Date:2013-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7102972-8905174400000X
UT7102972-1205174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTI17974Medicare UPIN