Healthcare Provider Details

I. General information

NPI: 1447267729
Provider Name (Legal Business Name): J MATTHEW HASLAM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 10/26/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1275 SAGE ST
GERING NE
69341-3227
US

IV. Provider business mailing address

1275 SAGE ST
GERING NE
69341-3227
US

V. Phone/Fax

Practice location:
  • Phone: 308-436-2101
  • Fax: 308-436-3681
Mailing address:
  • Phone: 308-436-2101
  • Fax: 308-436-3681

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number16128
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: