Basic Information
| Provider Information | |||||||||
| NPI: | 1801992615 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HURLBUTT | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | C. | ||||||||
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| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3420 WALBERT AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | ALLENTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 181041700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6103669160 | ||||||||
| FaxNumber: | 6103669164 | ||||||||
| Practice Location | |||||||||
| Address1: | 3420 WALBERT AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | ALLENTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 181041700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6103669160 | ||||||||
| FaxNumber: | 6103669164 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2006 | ||||||||
| LastUpdateDate: | 03/17/2009 | ||||||||
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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 | 2084N0400X | OS009485L | PA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 001647050 | 05 | PA | MEDICAID |