Provider Demographics
NPI:1699724179
Name:HANSELL, CHARLES E (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:E
Last Name:HANSELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1513 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:WI
Mailing Address - Zip Code:53925-1618
Mailing Address - Country:US
Mailing Address - Phone:920-623-9611
Mailing Address - Fax:920-623-1788
Practice Address - Street 1:1513 PARK AVE
Practice Address - Street 2:1ST FLOOR
Practice Address - City:COLUMBUS
Practice Address - State:WI
Practice Address - Zip Code:53925-1618
Practice Address - Country:US
Practice Address - Phone:920-623-9611
Practice Address - Fax:920-623-1788
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2014-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI19782-020207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1000156OtherPHYSICIANS PLUS
WI112354375Medicare PIN
WIK400130261Medicare PIN
WI006913215Medicare PIN
WI1000156OtherPHYSICIANS PLUS
WI1000156OtherPHYSICIANS PLUS
B53378Medicare UPIN