Provider Demographics
NPI:1831375369
Name:HANSON- MORAN EYE CLINIC PC
Entity type:Organization
Organization Name:HANSON- MORAN EYE CLINIC PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER OPHTHALMOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:MORAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:605-886-7722
Mailing Address - Street 1:705 14TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:SD
Mailing Address - Zip Code:57201-6827
Mailing Address - Country:US
Mailing Address - Phone:605-886-7874
Mailing Address - Fax:605-886-7723
Practice Address - Street 1:705 14TH AVE NE
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:SD
Practice Address - Zip Code:57201-6827
Practice Address - Country:US
Practice Address - Phone:605-886-7874
Practice Address - Fax:605-886-7723
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HANSON -MORAN EYE CLINIC PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-01-15
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD4579207W00000X, 332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332H00000XSuppliersEyewear Supplier
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD9280242Medicaid
SD4305930001Medicare NSC