Provider Demographics
NPI:1740691955
Name:HAZLETON MEDICAL PRACTICE LLC
Entity type:Organization
Organization Name:HAZLETON MEDICAL PRACTICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:PEDRO
Authorized Official - Middle Name:
Authorized Official - Last Name:GUZMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:570-497-4419
Mailing Address - Street 1:141 N CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:HAZLETON
Mailing Address - State:PA
Mailing Address - Zip Code:18201-5580
Mailing Address - Country:US
Mailing Address - Phone:570-497-4419
Mailing Address - Fax:570-497-4420
Practice Address - Street 1:141 N CEDAR ST
Practice Address - Street 2:
Practice Address - City:HAZLETON
Practice Address - State:PA
Practice Address - Zip Code:18201-5580
Practice Address - Country:US
Practice Address - Phone:570-497-4419
Practice Address - Fax:570-497-4420
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-12
Last Update Date:2020-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207R00000X
PAMD441284261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1174858104OtherMY NPI