Provider Demographics
NPI:1720204308
Name:PATRICIA M. HANNAN
Entity Type:Organization
Organization Name:PATRICIA M. HANNAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARY ANN
Authorized Official - Middle Name:
Authorized Official - Last Name:PENIX
Authorized Official - Suffix:
Authorized Official - Credentials:RN, MSN
Authorized Official - Phone:706-828-6868
Mailing Address - Street 1:110 PEPPER HILL WAY
Mailing Address - Street 2:
Mailing Address - City:AIKEN
Mailing Address - State:SC
Mailing Address - Zip Code:29801-2818
Mailing Address - Country:US
Mailing Address - Phone:706-828-6868
Mailing Address - Fax:706-828-7098
Practice Address - Street 1:611 TELFAIR ST
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30901-2324
Practice Address - Country:US
Practice Address - Phone:706-828-6868
Practice Address - Fax:706-828-7098
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2288261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCAN0591Medicaid
SCAN0591Medicaid