Provider Demographics
NPI:1295734135
Name:HANSON, KENNETH C JR (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:C
Last Name:HANSON
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7905 E CURTIS RD
Mailing Address - Street 2:
Mailing Address - City:FRANKENMUTH
Mailing Address - State:MI
Mailing Address - Zip Code:48734-9583
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:262-245-2248
Practice Address - Street 1:900 COOPER AVE
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48602-5182
Practice Address - Country:US
Practice Address - Phone:989-583-6521
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2021-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01054195A207P00000X
IL036-141304207PE0004X
WI65793-20207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIHANSOKENOtherMERCYCARE INSURANCE
IN000000198747OtherBLUE CROSS/BLUE SHIELD
IN000000640498OtherBC/BS
WI1295734135Medicaid
INP00775286OtherRAILROAD MEDICARE
IN000000668240OtherANTHEM BC/BS
IN200336440AMedicaid
INP00023838OtherRAIL ROAD
INP00841040OtherRAILROAD MEDICARE
WI1295734135OtherBCBSWI
IN000000668240OtherANTHEM BC/BS
IN295910IIIMedicare PIN
INP00841040OtherRAILROAD MEDICARE
WIHANSOKENOtherMERCYCARE INSURANCE
IN000000640498OtherBC/BS
IN000000668240OtherANTHEM BC/BS
IN265520SMedicare PIN