Healthcare Provider Details

I. General information

NPI: 1376798090
Provider Name (Legal Business Name): MICHAEL EDWARD HANLON LPTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2008
Last Update Date: 11/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7733 FORSYTH BLVD
SAINT LOUIS MO
63105-1817
US

IV. Provider business mailing address

28 MELWOOD DR
BELLEVILLE IL
62223-2905
US

V. Phone/Fax

Practice location:
  • Phone: 800-677-1238
  • Fax:
Mailing address:
  • Phone: 618-670-6239
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number160.002570
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code171W00000X
TaxonomyContractor
License Number120019
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: