Provider Demographics
NPI:1689636201
Name:HAWTHORNE MEDICAL ASSOCIATES PC
Entity Type:Organization
Organization Name:HAWTHORNE MEDICAL ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:SHELLEY
Authorized Official - Middle Name:D
Authorized Official - Last Name:DES JARDINES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-769-3331
Mailing Address - Street 1:120 HAWTHORNE PARK
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606-2147
Mailing Address - Country:US
Mailing Address - Phone:706-353-8700
Mailing Address - Fax:706-353-7228
Practice Address - Street 1:120 HAWTHORNE PARK
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-2147
Practice Address - Country:US
Practice Address - Phone:706-353-8700
Practice Address - Fax:706-353-7228
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-06
Last Update Date:2010-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GACC3389OtherRAILROAD MEDICARE
GA06965OtherBLUE CROSS/BLUE SHIELD
GA06965OtherBLUE CROSS/BLUE SHIELD