Provider Demographics
NPI:1023196318
Name:HAWTHORNE MEDICAL CENTER, INC.
Entity Type:Organization
Organization Name:HAWTHORNE MEDICAL CENTER, INC.
Other - Org Name:HAWTHORNE MEDICAL CENTER, PA
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:O
Authorized Official - Last Name:MCCULLOUGH
Authorized Official - Suffix:
Authorized Official - Credentials:RN COHN-S
Authorized Official - Phone:352-481-2400
Mailing Address - Street 1:21815 S.E .71ST AVENUE
Mailing Address - Street 2:
Mailing Address - City:HAWTHORNE
Mailing Address - State:FL
Mailing Address - Zip Code:32640-3974
Mailing Address - Country:US
Mailing Address - Phone:352-481-2400
Mailing Address - Fax:352-481-2777
Practice Address - Street 1:21815 S.E .71ST AVENUE
Practice Address - Street 2:
Practice Address - City:HAWTHORNE
Practice Address - State:FL
Practice Address - Zip Code:32640-3974
Practice Address - Country:US
Practice Address - Phone:352-481-2400
Practice Address - Fax:352-481-2777
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2009-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME63062207Q00000X
FLHCC8421207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL37209S100Medicaid
FL45696OtherBLUE CROSS BLUE SHIELD
FL18622OtherBLUE CROSS BLUE SHIELD
FLE66071Medicare UPIN
FL18622OtherBLUE CROSS BLUE SHIELD
FL45696OtherBLUE CROSS BLUE SHIELD
FL4235970001Medicare NSC