Provider Demographics
NPI:1841532231
Name:HANSEN, ERIC DAVID (BA)
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:DAVID
Last Name:HANSEN
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3708 N HERMITAGE AVE
Mailing Address - Street 2:APT 1
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-3509
Mailing Address - Country:US
Mailing Address - Phone:315-576-0590
Mailing Address - Fax:
Practice Address - Street 1:ELM AND CARLTON STREETS
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14263-4494
Practice Address - Country:US
Practice Address - Phone:716-845-2300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-23
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY288063207R00000X, 2081H0002X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081H0002XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationHospice and Palliative Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program