Healthcare Provider Details

I. General information

NPI: 1851363618
Provider Name (Legal Business Name): LAURENCE HABENICHT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2006
Last Update Date: 03/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

42 N SAINT JOSEPH AVE SUITE100
NILES MI
49120-2203
US

IV. Provider business mailing address

42 N SAINT JOSEPH AVE SUITE100
NILES MI
49120-2203
US

V. Phone/Fax

Practice location:
  • Phone: 269-684-6696
  • Fax: 269-684-5286
Mailing address:
  • Phone: 269-684-6696
  • Fax: 269-684-5286

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number4301074430
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number4301074430
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: