Healthcare Provider Details

I. General information

NPI: 1245687425
Provider Name (Legal Business Name): RACHEL HANSEN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2016
Last Update Date: 03/18/2021
Certification Date: 03/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

230 W BLACKHAWK DR
BYRON IL
61010-8988
US

IV. Provider business mailing address

PO BOX 78866
MILWAUKEE WI
53278-8866
US

V. Phone/Fax

Practice location:
  • Phone: 779-696-1300
  • Fax:
Mailing address:
  • Phone: 779-696-7150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036150946
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: