Basic Information
| Provider Information | |||||||||
| NPI: | 1861753485 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HABECK | ||||||||
| FirstName: | JASON | ||||||||
| MiddleName: | MARK | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 123 HOSPITAL DR | ||||||||
| Address2: | STE 1008 | ||||||||
| City: | WATERTOWN | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530983320 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9202066500 | ||||||||
| FaxNumber: | 9202614013 | ||||||||
| Practice Location | |||||||||
| Address1: | 13020 N TELECOM PKWY | ||||||||
| Address2: | |||||||||
| City: | TEMPLE TERRACE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336370925 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8139789700 | ||||||||
| FaxNumber: | 8135586187 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2012 | ||||||||
| LastUpdateDate: | 06/01/2018 | ||||||||
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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 | 207X00000X | 4301100883 | MI | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 390200000X | 4301100883 | MI | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207X00000X | ME130378 | FL | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | WC162 | 01 | FL | BCBS | OTHER | JA244Z | 01 | FL | MEDICARE | OTHER | 020408900 | 05 | FL | MEDICAID |