Provider Demographics
NPI:1689656936
Name:HAZZOURI, MICHELE A (MD)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:A
Last Name:HAZZOURI
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 1:937 HICKORY STREET
Mailing Address - Street 2:
Mailing Address - City:SCRANTON
Mailing Address - State:PA
Mailing Address - Zip Code:18505-2199
Mailing Address - Country:US
Mailing Address - Phone:570-346-5331
Mailing Address - Fax:570-207-5444
Practice Address - Street 1:937 HICKORY ST
Practice Address - Street 2:
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18505-2199
Practice Address - Country:US
Practice Address - Phone:570-346-5331
Practice Address - Fax:570-207-5444
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-14
Last Update Date:2022-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD038660L207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0007985320001Medicaid
6437925OtherAETNA PPO
PA0007985320001Medicaid
006895400OtherFEDERAL BLACK LUNG
PAB34807Medicare UPIN
PA4603575OtherAETNA SUPERIOR SYSTEM
PAHA67853OtherBLUE CROSS BLUE SHIELD
060000083Medicare ID - Type UnspecifiedRAILROAD MEDICARE
PAHA67853Medicare ID - Type Unspecified