Healthcare Provider Details

I. General information

NPI: 1245523091
Provider Name (Legal Business Name): STEPHANIE K. HAWLEY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2011
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 W JACKSON ST
CARBONDALE IL
62901-1462
US

IV. Provider business mailing address

105 LONGLEAF LN
NEW BERN NC
28562-3675
US

V. Phone/Fax

Practice location:
  • Phone: 618-549-0721
  • Fax: 618-457-0469
Mailing address:
  • Phone: 618-549-0721
  • Fax: 618-457-0469

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberC7-0004772
License Number StateDE
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number2014-00367
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number01077936A
License Number StateIN
# 4
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number036.141607
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: