Basic Information
| Provider Information | |||||||||
| NPI: | 1932364809 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HANISCH | ||||||||
| FirstName: | BENJAMIN | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 720 W LAKE ST | ||||||||
| Address2: | APT 201 | ||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554082963 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6126661141 | ||||||||
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| Practice Location | |||||||||
| Address1: | 111 MICHIGAN AVE NW | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON | ||||||||
| State: | DC | ||||||||
| PostalCode: | 200102916 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2024765000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2008 | ||||||||
| LastUpdateDate: | 07/23/2014 | ||||||||
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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 | 208000000X | 58043 | MN | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.