Basic Information
| Provider Information | |||||||||
| NPI: | 1376022954 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HAWTHORN ANESTHESIA LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 110 ROCHELLE AVE | ||||||||
| Address2: | |||||||||
| City: | ROCHELLE PARK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 076624329 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2016936953 | ||||||||
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| Practice Location | |||||||||
| Address1: | 104 LINCOLN AVE | ||||||||
| Address2: | |||||||||
| City: | HAWTHORNE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 075061436 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2013421205 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/14/2018 | ||||||||
| LastUpdateDate: | 08/14/2018 | ||||||||
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| AuthorizedOfficialLastName: | FINLEY | ||||||||
| AuthorizedOfficialFirstName: | TIMOTHY | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2016936953 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 25MB7591000 | NJ | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | BF8528082 | 01 | NJ | DO8394300 | OTHER | 25MB07591000 | 01 | NJ | 076130 | OTHER |