Provider Demographics
NPI:1104870724
Name:HANNAN, KATHLEEN LEE (MD)
Entity type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:LEE
Last Name:HANNAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:920 US HIGHWAY 84 W
Mailing Address - Street 2:
Mailing Address - City:THOMASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31792-0510
Mailing Address - Country:US
Mailing Address - Phone:229-228-8857
Mailing Address - Fax:
Practice Address - Street 1:915 GORDON AVE
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:GA
Practice Address - Zip Code:31792-6614
Practice Address - Country:US
Practice Address - Phone:229-228-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-19
Last Update Date:2008-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0565722085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000810851YMedicaid
FL252662000Medicaid
GA30BDMMTMedicare ID - Type Unspecified
GAF04978Medicare UPIN
P00396315Medicare PIN
FL41705TMedicare PIN