Healthcare Provider Details

I. General information

NPI: 1689656936
Provider Name (Legal Business Name): MICHELE A HAZZOURI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/14/2005
Last Update Date: 09/22/2022
Certification Date: 09/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

937 HICKORY ST
SCRANTON PA
18505-2199
US

IV. Provider business mailing address

937 HICKORY STREET
SCRANTON PA
18505-2199
US

V. Phone/Fax

Practice location:
  • Phone: 570-346-5331
  • Fax: 570-207-5444
Mailing address:
  • Phone: 570-346-5331
  • Fax: 570-207-5444

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD038660L
License Number StatePA

VII. Legacy identifiers

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

# 1
Identifier0007985320001
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: