Provider Demographics
NPI:1952464638
Name:HAZLETON PROFESSIONAL SERVICES
Entity Type:Organization
Organization Name:HAZLETON PROFESSIONAL SERVICES
Other - Org Name:LEHIGH VALLEY PHYSICIAN GROUP-HAZLETON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR VP & COO
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:DEMOPOULOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:484-884-4500
Mailing Address - Street 1:PO BOX 1830
Mailing Address - Street 2:
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18105-1830
Mailing Address - Country:US
Mailing Address - Phone:570-501-6368
Mailing Address - Fax:570-501-4754
Practice Address - Street 1:700 EAST BROAD STREET
Practice Address - Street 2:
Practice Address - City:HAZLETON
Practice Address - State:PA
Practice Address - Zip Code:18201-6835
Practice Address - Country:US
Practice Address - Phone:570-501-4584
Practice Address - Fax:570-501-4754
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GREATER HAZLETON HEALTH ALLIANCE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-18
Last Update Date:2022-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1019653980001Medicaid
PA1954699OtherHIGHMARK BLUE SHIELD
PA110308Medicare PIN