Provider Demographics
NPI:1033165428
Name:HANLON, KATHRYN A (MD)
Entity Type:Individual
Prefix:DR
First Name:KATHRYN
Middle Name:A
Last Name:HANLON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 N NILES AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-1924
Mailing Address - Country:US
Mailing Address - Phone:574-647-1610
Mailing Address - Fax:
Practice Address - Street 1:100 NAVARRE PL STE 6600
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-1173
Practice Address - Country:US
Practice Address - Phone:574-647-8800
Practice Address - Fax:574-647-8811
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01038697A2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100098910AMedicaid
IN100098910AMedicaid
IN000000908776OtherBCBS BMG IRELAND RD
IN100098910AMedicaid
INE14053Medicare UPIN
IN169380017Medicare PIN