Provider Demographics
NPI:1255446183
Name:HANLEY, MARYELLEN L (MD)
Entity type:Individual
Prefix:
First Name:MARYELLEN
Middle Name:L
Last Name:HANLEY
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:P.O. BOX 416524
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-6524
Mailing Address - Country:US
Mailing Address - Phone:973-971-7080
Mailing Address - Fax:973-290-8312
Practice Address - Street 1:95 MADISON AVENUE
Practice Address - Street 2:SUITE 203
Practice Address - City:MORRISTOWN
Practice Address - State:NJ
Practice Address - Zip Code:07960-1905
Practice Address - Country:US
Practice Address - Phone:973-971-7080
Practice Address - Fax:973-290-8312
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2011-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA05844300174400000X
NJ25MA05844200174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJG04773Medicare UPIN
714174Medicare ID - Type Unspecified