Basic Information
| Provider Information | |||||||||
| NPI: | 1952464638 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HAZLETON PROFESSIONAL SERVICES | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LEHIGH VALLEY PHYSICIAN GROUP-HAZLETON | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1830 | ||||||||
| Address2: | |||||||||
| City: | ALLENTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 181051830 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5705016368 | ||||||||
| FaxNumber: | 5705014754 | ||||||||
| Practice Location | |||||||||
| Address1: | 700 EAST BROAD STREET | ||||||||
| Address2: | |||||||||
| City: | HAZLETON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 182016835 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5705014584 | ||||||||
| FaxNumber: | 5705014754 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/18/2006 | ||||||||
| LastUpdateDate: | 05/11/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DEMOPOULOS | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SR VP & COO | ||||||||
| AuthorizedOfficialTelephone: | 4848844500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | GREATER HAZLETON HEALTH ALLIANCE | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111N00000X | N | 193200000X MULTI-SPECIALTY GROUP | Chiropractic Providers | Chiropractor | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 208100000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 208600000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | 213E00000X | N | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1019653980001 | 05 | PA | MEDICAID | 1954699 | 01 | PA | HIGHMARK BLUE SHIELD | OTHER |