Healthcare Provider Details

I. General information

NPI: 1932364809
Provider Name (Legal Business Name): BENJAMIN R HANISCH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2008
Last Update Date: 07/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 MICHIGAN AVE NW
WASHINGTON DC
20010-2916
US

IV. Provider business mailing address

720 W LAKE ST APT 201
MINNEAPOLIS MN
55408-2963
US

V. Phone/Fax

Practice location:
  • Phone: 202-476-5000
  • Fax:
Mailing address:
  • Phone: 612-666-1141
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number58043
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: