Provider Demographics
NPI:1790821460
Name:SUSAN WEAVER HAWN, MD, LLC
Entity Type:Organization
Organization Name:SUSAN WEAVER HAWN, MD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:W
Authorized Official - Last Name:HAWN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-367-7621
Mailing Address - Street 1:PO BOX 820
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON
Mailing Address - State:GA
Mailing Address - Zip Code:30549-0820
Mailing Address - Country:US
Mailing Address - Phone:706-367-7621
Mailing Address - Fax:706-367-2192
Practice Address - Street 1:85 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:JEFFERSON
Practice Address - State:GA
Practice Address - Zip Code:30549-1257
Practice Address - Country:US
Practice Address - Phone:706-367-7621
Practice Address - Fax:706-367-2192
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2011-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA037562207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA037562OtherSTATE LICENSE NUMBER
GA00838318AMedicaid
GA702182OtherBCBS PROVIDER NUMBER
GA00665OtherBCBS GROUP NUMBER
GA037562OtherSTATE LICENSE NUMBER
GA00838318AMedicaid
GA=========OtherTAX ID NUMBER