=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093713851
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BERNIE HP HANSON MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/14/2005
-----------------------------------------------------
Last Update Date | 09/12/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1425 MICKELSON DR.
-----------------------------------------------------
City | WATERTOWN
-----------------------------------------------------
State | SD
-----------------------------------------------------
Zip | 57201-6827
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 605-599-7411
-----------------------------------------------------
Fax | 605-578-6021
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1000 29TH ST SE
-----------------------------------------------------
City | WATERTOWN
-----------------------------------------------------
State | SD
-----------------------------------------------------
Zip | 57201-9120
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 605-520-3528
-----------------------------------------------------
Fax | 605-578-6021
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number | 0963
-----------------------------------------------------
License Number State | SD
-----------------------------------------------------