Provider Demographics
NPI:1841458395
Name:KENNETH J. HATHAWAY DO, INC
Entity type:Organization
Organization Name:KENNETH J. HATHAWAY DO, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:J
Authorized Official - Last Name:HATHAWAY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:401-783-3334
Mailing Address - Street 1:360 KINGSTOWN RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:NARRAGANSETT
Mailing Address - State:RI
Mailing Address - Zip Code:02882-3239
Mailing Address - Country:US
Mailing Address - Phone:401-783-3334
Mailing Address - Fax:401-783-9270
Practice Address - Street 1:360 KINGSTOWN RD
Practice Address - Street 2:SUITE 101
Practice Address - City:NARRAGANSETT
Practice Address - State:RI
Practice Address - Zip Code:02882-3239
Practice Address - Country:US
Practice Address - Phone:401-783-3334
Practice Address - Fax:401-783-9270
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-30
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIDO278207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI3623-2OtherBLUE CROSS BLUE SHIELD OF RI
RI9003623Medicaid
RI3623OtherFEDERAL BLUE CROSS
RI709006125Medicare PIN
RI9003623Medicaid