Provider Demographics
NPI:1073781118
Name:MAILLOUX, PETER B
Entity Type:Individual
Prefix:MR
First Name:PETER
Middle Name:B
Last Name:MAILLOUX
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1275 SANS SOUCI PKWY
Mailing Address - Street 2:
Mailing Address - City:HANOVER TWP
Mailing Address - State:PA
Mailing Address - Zip Code:18706-5229
Mailing Address - Country:US
Mailing Address - Phone:570-445-9214
Mailing Address - Fax:570-550-9907
Practice Address - Street 1:1275 SANS SOUCI PKWY
Practice Address - Street 2:
Practice Address - City:HANOVER TWP
Practice Address - State:PA
Practice Address - Zip Code:18706-5229
Practice Address - Country:US
Practice Address - Phone:570-445-9214
Practice Address - Fax:570-550-9907
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-12
Last Update Date:2023-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA6000006843332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA5712580001Medicare PIN