Healthcare Provider Details

I. General information

NPI: 1275535205
Provider Name (Legal Business Name): THOMAS W HANLON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2005
Last Update Date: 01/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

631 AIRPORT ROAD SUITE 101
HAZLETON PA
18202
US

IV. Provider business mailing address

PO BOX 70
MOUNTAIN TOP PA
18707-0070
US

V. Phone/Fax

Practice location:
  • Phone: 570-861-8200
  • Fax: 570-861-8205
Mailing address:
  • Phone: 570-861-8200
  • Fax: 570-861-8205

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberMD044497L
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier0012583000010
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer
# 2
Identifier0012583000011
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: