1760461925 NPI number — JOSEPH M HATHAWAY JR. MD

Table of content: JOSEPH M HATHAWAY JR. MD (NPI 1760461925)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760461925 NPI number — JOSEPH M HATHAWAY JR. MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HATHAWAY
Provider First Name:
JOSEPH
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
JR.
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1760461925
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/20/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
114 HILL POND LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STATESBORO
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30458-0872
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
912-681-6944
Provider Business Mailing Address Fax Number:
912-681-8744

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1497 FAIR RD STE 104
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STATESBORO
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30458-0822
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
912-486-1600
Provider Business Practice Location Address Fax Number:
912-871-3342
Provider Enumeration Date:
01/15/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RG0100X , with the licence number:  049797 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000900501G , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".