Provider Demographics
NPI:1124462981
Name:HERITAGE FAMILY MEDICINE, LLC
Entity type:Organization
Organization Name:HERITAGE FAMILY MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:HAWKINS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-547-2209
Mailing Address - Street 1:101 E WISCONSIN AVE
Mailing Address - Street 2:
Mailing Address - City:BONIFAY
Mailing Address - State:FL
Mailing Address - Zip Code:32425-1809
Mailing Address - Country:US
Mailing Address - Phone:850-547-2209
Mailing Address - Fax:850-547-4521
Practice Address - Street 1:101 E WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:BONIFAY
Practice Address - State:FL
Practice Address - Zip Code:32425-1809
Practice Address - Country:US
Practice Address - Phone:850-547-2209
Practice Address - Fax:850-547-4521
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-24
Last Update Date:2013-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME105126207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLFH128ZOtherMEDICARE PTAN
FL372395000Medicaid
FL003587000Medicaid
FL18651OtherMEDICARE PTAN