Basic Information
| Provider Information | |||||||||
| NPI: | 1205942406 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HANSEN | ||||||||
| FirstName: | ERIC | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1330 COSHOCTON AVE | ||||||||
| Address2: | |||||||||
| City: | MOUNT VERNON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 43050 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403939000 | ||||||||
| FaxNumber: | 7403920167 | ||||||||
| Practice Location | |||||||||
| Address1: | 1330 COSHOCTON AVE | ||||||||
| Address2: | |||||||||
| City: | MOUNT VERNON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 43050 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403939000 | ||||||||
| FaxNumber: | 7403920167 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2006 | ||||||||
| LastUpdateDate: | 03/05/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 35073065 | OH | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207Q00000X | 35073065 | OH | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 35.073065 | OH | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2043443 | 05 | OH | MEDICAID | 000000187190 | 01 | BCBS | OTHER | P00149373 | 01 | RR MCR | OTHER | P01243229 | 01 | OH | RAILROAD MEDICARE | OTHER |