Provider Demographics
NPI:1013990787
Name:HAWTHORNE, MARY R (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:R
Last Name:HAWTHORNE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 415348
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-5348
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:291 LINCOLN ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01605-3643
Practice Address - Country:US
Practice Address - Phone:508-791-8524
Practice Address - Fax:508-754-6771
Is Sole Proprietor?:No
Enumeration Date:2005-11-27
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA51975207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA6175163Medicaid
MAMX3170Medicare PIN
MAA56858Medicare UPIN