Healthcare Provider Details

I. General information

NPI: 1124462981
Provider Name (Legal Business Name): HERITAGE FAMILY MEDICINE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2013
Last Update Date: 04/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 E WISCONSIN AVE
BONIFAY FL
32425-1809
US

IV. Provider business mailing address

101 E WISCONSIN AVE
BONIFAY FL
32425-1809
US

V. Phone/Fax

Practice location:
  • Phone: 850-547-2209
  • Fax: 850-547-4521
Mailing address:
  • Phone: 850-547-2209
  • Fax: 850-547-4521

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME105126
License Number StateFL

VIII. Authorized Official

Name: DR. PATRICK HAWKINS
Title or Position: PHYSICIAN
Credential: M.D.
Phone: 850-547-2209