Provider Demographics
NPI:1922458439
Name:AWAKENMD PC
Entity Type:Organization
Organization Name:AWAKENMD PC
Other - Org Name:AWAKENMD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:FOUNDER AND MEDICAL DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:SEAN
Authorized Official - Middle Name:E
Authorized Official - Last Name:BOURKE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:650-274-6256
Mailing Address - Street 1:36 STANFORD SHOPPING CENTER
Mailing Address - Street 2:
Mailing Address - City:PALO ALTO
Mailing Address - State:CA
Mailing Address - Zip Code:94304-1423
Mailing Address - Country:US
Mailing Address - Phone:650-251-4722
Mailing Address - Fax:650-421-7494
Practice Address - Street 1:95 TOWN AND COUNTRY VILLAGE
Practice Address - Street 2:
Practice Address - City:PALO ALTO
Practice Address - State:CA
Practice Address - Zip Code:94301-2341
Practice Address - Country:US
Practice Address - Phone:650-251-4722
Practice Address - Fax:650-421-7494
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-15
Last Update Date:2016-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty