Basic Information
| Provider Information | |||||||||
| NPI: | 1609936178 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HABERKERN | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 50010 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981051010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2069878450 | ||||||||
| FaxNumber: | 2069878484 | ||||||||
| Practice Location | |||||||||
| Address1: | 4800 SAND POINT WAY NE | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981053901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2069872518 | ||||||||
| FaxNumber: | 2069873935 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/12/2006 | ||||||||
| LastUpdateDate: | 02/02/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | MD00014958 | WA | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207LP3000X | MD00014958 | WA | Y | Allopathic & Osteopathic Physicians | Anesthesiology | Pediatric Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 8426314 | 05 | WA | MEDICAID |