Provider Demographics
NPI:1134458433
Name:KENNETH B HAWTHORNE JR MD PA
Entity Type:Organization
Organization Name:KENNETH B HAWTHORNE JR MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:B
Authorized Official - Last Name:HAWTHORNE
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:386-671-0115
Mailing Address - Street 1:106 N OLD KINGS RD
Mailing Address - Street 2:STE E
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-9505
Mailing Address - Country:US
Mailing Address - Phone:386-671-0115
Mailing Address - Fax:386-671-0844
Practice Address - Street 1:106 N OLD KINGS RD
Practice Address - Street 2:STE E
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-9505
Practice Address - Country:US
Practice Address - Phone:386-671-0115
Practice Address - Fax:386-671-0844
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-15
Last Update Date:2011-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CS854AMedicare PIN