1811943335 NPI number — PETER HANNON DO

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811943335 NPI number — PETER HANNON DO

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

HANNON

Provider First Name:

PETER

Provider Middle Name:

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:

DO

Provider Gender Code:

M

Provider Other Organization Name:

Provider Other Organization Name Type Code:

Provider Other Last Name:

Provider Other First Name:

Provider Other Middle Name:

Provider Other Name Prefix Text:

Provider Other Name Suffix Text:

Provider Other Credential Text:

Provider Other Last Name Type Code:

NPI Number:

1811943335

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

06/27/2023

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

100 N ACADEMY AVE

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

DANVILLE

Provider Business Mailing Address State Name:

PA

Provider Business Mailing Address Postal Code:

17822-4903

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

570-271-6144

Provider Business Mailing Address Fax Number:

570-271-6578

Provider First Line Business Practice Location Address:

1000 EAST MOUNTAIN BLVD

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:

WILKES BARRE

Provider Business Practice Location Address State Name:

PA

Provider Business Practice Location Address Postal Code:

18711-3478

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

570-808-7856

Provider Business Practice Location Address Fax Number:

570-808-1069

Provider Enumeration Date:

05/26/2006

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

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• Taxonomy code: 207R00000X , with the licence number:  OS007131L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 207RC0200X , with the licence number: 12826434-1204 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 207RC0200X , with the licence number: 195753 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 208M00000X , with the licence number: OS007131L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 207RC0200X , with the licence number: OS-007131-L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 50073483 . This is a "KEYSTONE HEALTH PLAN" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
• Identifier: HA425022 . This is a "HIGHMARK BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
• Identifier: 232809429008 . This is a "TRICARE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
• Identifier: 0013918390006 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
• Identifier: 50073483 . This is a "CAPITAL BLUE CROSS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
• Identifier: 1689 . This is a "GEISINGER" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".