Provider Demographics
NPI:1023354289
Name:HAWTHORN KIDNEY CENTER WAREHAM LLC
Entity type:Organization
Organization Name:HAWTHORN KIDNEY CENTER WAREHAM LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:WILCOX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:978-922-3080
Mailing Address - Street 1:2991 CRANBERRY HWY
Mailing Address - Street 2:SUITE F1
Mailing Address - City:EAST WAREHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02538-1354
Mailing Address - Country:US
Mailing Address - Phone:508-295-5290
Mailing Address - Fax:508-295-5291
Practice Address - Street 1:2991 CRANBERRY HWY
Practice Address - Street 2:SUITE F1
Practice Address - City:EAST WAREHAM
Practice Address - State:MA
Practice Address - Zip Code:02538-1354
Practice Address - Country:US
Practice Address - Phone:508-295-5290
Practice Address - Fax:508-295-5291
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-17
Last Update Date:2017-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110096821AMedicaid
MA222578Medicare Oscar/Certification