Basic Information
| Provider Information | |||||||||
| NPI: | 1548292063 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HAIDET | ||||||||
| FirstName: | PAUL | ||||||||
| MiddleName: | MATTHEW | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 858 | ||||||||
| Address2: | MC A410 | ||||||||
| City: | HERSHEY | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170330858 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002431455 | ||||||||
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| Practice Location | |||||||||
| Address1: | 500 UNIVERSITY DR | ||||||||
| Address2: | |||||||||
| City: | HERSHEY | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170332360 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7175314221 | ||||||||
| FaxNumber: | 7175310151 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2006 | ||||||||
| LastUpdateDate: | 01/17/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 82142 | MA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | MD052613L | PA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0014679640004 | 05 | PA | MEDICAID |