Healthcare Provider Details

I. General information

NPI: 1689172504
Provider Name (Legal Business Name): MICHAEL HANNON MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2018
Last Update Date: 01/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

99 N LA CIENEGA BLVD STE 304
BEVERLY HILLS CA
90211-2286
US

IV. Provider business mailing address

3 STRATFORD
MANHATTAN BEACH CA
90266-7224
US

V. Phone/Fax

Practice location:
  • Phone: 310-362-3099
  • Fax:
Mailing address:
  • Phone: 703-774-4850
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License NumberA123393
License Number StateCA

VIII. Authorized Official

Name: DR. MICHAEL G HANNON
Title or Position: OWNER/PRESIDENT
Credential: MD
Phone: 914-433-1654