MEDICARE: DR. THADDEUS MICHAEL MIDAS PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TP2701X	Group Psychotherapy Psychologist	PS003455-L	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	818748	OTHER	PA	NORTHEAST BLUE CROSS BLUE SHIELD
2	4455111	OTHER	PA	AETNA
3	50008809	OTHER	PA	CAPITAL BLUE CROSS

General Provider Information

NPI Number	:	1740249630
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. THADDEUS MICHAEL MIDAS PH.D.

Provider Business Mailing Address
First Line	:	701 BRIDGE ST
Second Line	:	SUITE 206
City	:	LEHIGHTON
State	:	PA
Zip	:	18235-1800
Country	:	US
Telephone Number	:	610-377-6155
Fax Number	:	610-377-9765

Provider Business Practice Location Address
First Line	:	701 BRIDGE ST
Second Line	:	SUITE 206
City	:	LEHIGHTON
State	:	PA
Zip	:	18235-1800
Country	:	US
Telephone Number	:	610-377-6155
Fax Number	:	610-377-9765

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/21/2006
Last Update Date	:	12/10/2013

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