MEDICARE: HAZLETON MEDICAL PRACTICE LLC

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	261QP2300X	Primary Care Clinic/Center	MD441284	PA
2	207R00000X	Internal Medicine Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1174858104	OTHER		MY NPI

General Provider Information

NPI Number	:	1740691955
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HAZLETON MEDICAL PRACTICE LLC

Provider Business Mailing Address
First Line	:	141 N CEDAR ST
Second Line	:
City	:	HAZLETON
State	:	PA
Zip	:	18201-5580
Country	:	US
Telephone Number	:	570-497-4419
Fax Number	:	570-497-4420

Provider Business Practice Location Address
First Line	:	141 N CEDAR ST
Second Line	:
City	:	HAZLETON
State	:	PA
Zip	:	18201-5580
Country	:	US
Telephone Number	:	570-497-4419
Fax Number	:	570-497-4420

Authorized Official
Title or Position	:	DIRECTOR
Name	:	MR. PEDRO GUZMAN
Credential	:	MD
Telephone Number	:	570-497-4419

Provider Enumeration Date	:	05/12/2014
Last Update Date	:	02/14/2020

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Directions to “HAZLETON MEDICAL PRACTICE LLC ” Practice Location

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