Basic Information
| Provider Information | |||||||||
| NPI: | 1174755169 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HABEN PRACTICE FOR VOICE & LARYNGEAL LASER SURGERY PLLC | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 980 WESTFALL RD | ||||||||
| Address2: | SUITE 1-127 | ||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146182605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5857275436 | ||||||||
| FaxNumber: | 9999999999 | ||||||||
| Practice Location | |||||||||
| Address1: | 980 WESTFALL RD | ||||||||
| Address2: | SUITE 1-127 | ||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146182605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5857275436 | ||||||||
| FaxNumber: | 9999999999 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2009 | ||||||||
| LastUpdateDate: | 08/10/2009 | ||||||||
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| AuthorizedOfficialLastName: | HABEN | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5857275436 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD, MSC | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 230501 | NY | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | BH8597429 | 01 | DEA | OTHER | 230501 | 01 | NY | LICENSE | OTHER | 02553175 | 05 | NY | MEDICAID |