Provider Demographics
NPI:1174593735
Name:HANSEN, MATTHEW P (DPM)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:P
Last Name:HANSEN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:9400 S CICERO AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-2536
Mailing Address - Country:US
Mailing Address - Phone:708-424-3201
Mailing Address - Fax:708-424-5001
Practice Address - Street 1:32743 23 MILE RD STE 110
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MI
Practice Address - Zip Code:48047-2082
Practice Address - Country:US
Practice Address - Phone:586-725-3444
Practice Address - Fax:586-725-0984
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2025-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901002044213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI148898OtherGREAT LAKES HEALTH PLAN
MI139713OtherCARE CHOICES
MI000000012442OtherCAPE
MI4941655Medicaid
MI16993OtherM-CARE
MI7057667OtherAETNA
MI4941655Medicaid
0420490001Medicare NSC
0E06226011Medicare PIN