MEDICARE: JACK HAWKS PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	4049	AZ

General Provider Information

NPI Number	:	1972626141
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JACK HAWKS PC

Provider Business Mailing Address
First Line	:	9191 W THUNDERBIRD ROAD
Second Line	:	D 105
City	:	PEORIA
State	:	AZ
Zip	:	85381
Country	:	US
Telephone Number	:	623-849-3811
Fax Number	:	623-849-5221

Provider Business Practice Location Address
First Line	:	9191 W THUNDERBIRD ROAD
Second Line	:	D 105
City	:	PEORIA
State	:	AZ
Zip	:	85381
Country	:	US
Telephone Number	:	623-849-3811
Fax Number	:	623-849-5221

Authorized Official
Title or Position	:	PHYSICIAN
Name	:	DR. JACK HAWKS
Credential	:	DO
Telephone Number	:	623-849-3811

Provider Enumeration Date	:	04/10/2007
Last Update Date	:	01/20/2011

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