Provider Demographics
NPI:1699957357
Name:HANSEN, LAWRENCE ALLEN (MD)
Entity type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:ALLEN
Last Name:HANSEN
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 1:7445 ALLEN RD
Mailing Address - Street 2:SUITE 190
Mailing Address - City:ALLEN PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48101-1993
Mailing Address - Country:US
Mailing Address - Phone:313-382-2184
Mailing Address - Fax:313-382-2189
Practice Address - Street 1:7445 ALLEN RD
Practice Address - Street 2:SUITE 190
Practice Address - City:ALLEN PARK
Practice Address - State:MI
Practice Address - Zip Code:48101-1993
Practice Address - Country:US
Practice Address - Phone:313-382-2184
Practice Address - Fax:313-382-2189
Is Sole Proprietor?:No
Enumeration Date:2007-12-04
Last Update Date:2008-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301407500208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0825978OtherBLUE CROSS BLUE SHIELD
F10769Medicare UPIN
0N38310Medicare PIN