Provider Demographics
NPI:1447449079
Name:CRAIG K. HANSEN
Entity type:Organization
Organization Name:CRAIG K. HANSEN
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:K
Authorized Official - Last Name:HANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:605-348-1208
Mailing Address - Street 1:2620 JACKSON BLVD
Mailing Address - Street 2:SUITE C
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57702-3478
Mailing Address - Country:US
Mailing Address - Phone:605-341-1208
Mailing Address - Fax:605-341-3552
Practice Address - Street 1:2620 JACKSON BLVD
Practice Address - Street 2:SUITE C
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57702-3478
Practice Address - Country:US
Practice Address - Phone:605-341-1208
Practice Address - Fax:605-341-3552
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-19
Last Update Date:2008-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SDS1792Medicare PIN