Healthcare Provider Details

I. General information

NPI: 1730505074
Provider Name (Legal Business Name): HAWTHORNE INTEGRATED MEDICINE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/11/2014
Last Update Date: 03/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

219 LAFAYETTE AVE
HAWTHORNE NJ
07506-1904
US

IV. Provider business mailing address

219 LAFAYETTE AVE
HAWTHORNE NJ
07506-1904
US

V. Phone/Fax

Practice location:
  • Phone: 973-423-9100
  • Fax: 973-423-1339
Mailing address:
  • Phone: 973-423-9100
  • Fax: 973-423-1339

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number25MB08249300
License Number StateNJ

VIII. Authorized Official

Name: DR. JOHN GREGG
Title or Position: PRESIDENT/OWNER
Credential: MD
Phone: 973-423-9100