Basic Information
| Provider Information | |||||||||
| NPI: | 1396705596 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HAMILTON | ||||||||
| FirstName: | GARRY | ||||||||
| MiddleName: | A. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 206 E BROWN ST | ||||||||
| Address2: | POCONO HEALTHCARE MANAGEMENT - PROFESSIONAL BLDG. | ||||||||
| City: | E STROUDSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 183013006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5704204951 | ||||||||
| FaxNumber: | 5704763754 | ||||||||
| Practice Location | |||||||||
| Address1: | 175 E BROWN ST STE 108 | ||||||||
| Address2: | POCONO KIDS PEDIATRICS | ||||||||
| City: | EAST STROUDSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 183013098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5704763585 | ||||||||
| FaxNumber: | 5704219014 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2006 | ||||||||
| LastUpdateDate: | 06/15/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | MD423683 | PA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 1009373070001 | 05 | PA | MEDICAID |