Healthcare Provider Details

I. General information

NPI: 1619128923
Provider Name (Legal Business Name): MICHAEL ANDREW HAVENS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/06/2008
Last Update Date: 01/24/2024
Certification Date: 01/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6528 N OLYMPIA AVE
CHICAGO IL
60631-1520
US

IV. Provider business mailing address

1000 N WESTMORELAND RD # LL0519
LAKE FOREST IL
60045-1658
US

V. Phone/Fax

Practice location:
  • Phone: 773-792-8112
  • Fax:
Mailing address:
  • Phone: 847-535-6218
  • Fax: 847-535-6237

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZC0500X
TaxonomyCytopathology Physician
License Number036120021
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number036120021
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: