1093890055 NPI number — CHRISTINA M HAWTHORNE DPM

Table of content: CHRISTINA M HAWTHORNE DPM (NPI 1093890055)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093890055 NPI number — CHRISTINA M HAWTHORNE DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HAWTHORNE
Provider First Name:
CHRISTINA
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPM
Provider Gender Code:
F

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:
1093890055
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/02/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12255 DE PAUL DR
Provider Second Line Business Mailing Address:
STE 470
Provider Business Mailing Address City Name:
BRIDGETON
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63044-2510
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-739-8863
Provider Business Mailing Address Fax Number:
314-739-6448

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12255 DE PAUL DR
Provider Second Line Business Practice Location Address:
STE 470
Provider Business Practice Location Address City Name:
BRIDGETON
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63044-2510
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-739-8863
Provider Business Practice Location Address Fax Number:
314-739-6448
Provider Enumeration Date:
10/26/2006

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: 213ES0103X , with the licence number:  000559 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2700497 . This is a "UHC" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 49331 . This is a "BLUE CROSS" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 1984900 . This is a "CIGNA" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 303231500 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: CK3051 . This is a "RR MEDICARE" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




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