Basic Information
Provider Information | |||||||||
NPI: | 1932101532 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HAWN | ||||||||
FirstName: | KENNETH | ||||||||
MiddleName: | D | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 509 HAMACHER ST | ||||||||
Address2: | SUITE 103 | ||||||||
City: | WATERLOO | ||||||||
State: | IL | ||||||||
PostalCode: | 622981592 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6189392273 | ||||||||
FaxNumber: | 6189390245 | ||||||||
Practice Location | |||||||||
Address1: | 509 HAMACHER ST | ||||||||
Address2: | SUITE 103 | ||||||||
City: | WATERLOO | ||||||||
State: | IL | ||||||||
PostalCode: | 622981592 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6189392273 | ||||||||
FaxNumber: | 6189390245 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/12/2005 | ||||||||
LastUpdateDate: | 08/27/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | E-4451 | AR | N |   | Allopathic & Osteopathic Physicians | Pediatrics |   | 208000000X | 2003018920 | MO | N |   | Allopathic & Osteopathic Physicians | Pediatrics |   | 208000000X | 036135043 | IL | Y |   | Allopathic & Osteopathic Physicians | Pediatrics |   |
ID Information
ID | Type | State | Issuer | Description | 157028001 | 05 | AR |   | MEDICAID |