Healthcare Provider Details

I. General information

NPI: 1700140563
Provider Name (Legal Business Name): CALLIE ELIZABETH HANSEN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2012
Last Update Date: 03/01/2021
Certification Date: 03/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4855 S MOORLAND RD
NEW BERLIN WI
53151-7494
US

IV. Provider business mailing address

9000 W WISCONSIN AVE # MS 958
MILWAUKEE WI
53226-4874
US

V. Phone/Fax

Practice location:
  • Phone: 262-432-7599
  • Fax: 262-432-7694
Mailing address:
  • Phone: 262-432-7599
  • Fax: 262-432-7694

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number74482-20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: