Healthcare Provider Details

I. General information

NPI: 1336175801
Provider Name (Legal Business Name): HAWTHORNE PHYSICAL MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2006
Last Update Date: 01/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

977 LAKEVIEW PKWY SUITE#103
VERNON HILLS IL
60061-1400
US

IV. Provider business mailing address

977 LAKEVIEW PKWY SUITE#103
VERNON HILLS IL
60061-1400
US

V. Phone/Fax

Practice location:
  • Phone: 847-932-1079
  • Fax: 847-932-1082
Mailing address:
  • Phone: 847-932-1079
  • Fax: 847-932-1082

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number042-617702
License Number StateIL

VIII. Authorized Official

Name: BRADLEY MATTSON
Title or Position: OWNER
Credential:
Phone: 847-932-1079