Basic Information
| Provider Information | |||||||||
| NPI: | 1174593735 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HANSEN | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | P | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.P.M. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 32743 23 MILE RD | ||||||||
| Address2: | STE 210 | ||||||||
| City: | CHESTERFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480471985 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5867253444 | ||||||||
| FaxNumber: | 5867250984 | ||||||||
| Practice Location | |||||||||
| Address1: | 32743 23 MILE RD | ||||||||
| Address2: | STE 210 | ||||||||
| City: | CHESTERFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480471985 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5867253444 | ||||||||
| FaxNumber: | 5867250984 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2006 | ||||||||
| LastUpdateDate: | 01/11/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | 5901002044 | MI | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist |
ID Information
| ID | Type | State | Issuer | Description | 148898 | 01 | MI | GREAT LAKES HEALTH PLAN | OTHER | 139713 | 01 | MI | CARE CHOICES | OTHER | 000000012442 | 01 | MI | CAPE | OTHER | 4941655 | 05 | MI | MEDICAID | 16993 | 01 | MI | M-CARE | OTHER | 7057667 | 01 | MI | AETNA | OTHER |