Healthcare Provider Details

I. General information

NPI: 1740691955
Provider Name (Legal Business Name): HAZLETON MEDICAL PRACTICE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2014
Last Update Date: 02/14/2020
Certification Date: 02/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

141 N CEDAR ST
HAZLETON PA
18201-5580
US

IV. Provider business mailing address

141 N CEDAR ST
HAZLETON PA
18201-5580
US

V. Phone/Fax

Practice location:
  • Phone: 570-497-4419
  • Fax: 570-497-4420
Mailing address:
  • Phone: 570-497-4419
  • Fax: 570-497-4420

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License NumberMD441284
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VII. Legacy identifiers

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

# 1
Identifier1174858104
Identifier TypeOTHER
Identifier State
Identifier IssuerMY NPI

VIII. Authorized Official

Name: MR. PEDRO GUZMAN
Title or Position: DIRECTOR
Credential: MD
Phone: 570-497-4419