Healthcare Provider Details

I. General information

NPI: 1992920169
Provider Name (Legal Business Name): PAUL L. HANNAH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/14/2007
Last Update Date: 09/02/2021
Certification Date: 09/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3787 GRANT ST
GARY IN
46408-2142
US

IV. Provider business mailing address

3787 GRANT ST
GARY IN
46408-2142
US

V. Phone/Fax

Practice location:
  • Phone: 219-981-4800
  • Fax: 219-981-4805
Mailing address:
  • Phone: 219-981-4800
  • Fax: 219-981-4805

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number01031585
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number01031585
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: