Healthcare Provider Details

I. General information

NPI: 1306254594
Provider Name (Legal Business Name): KIM HABERER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2014
Last Update Date: 06/23/2021
Certification Date: 06/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3415 BAINBRIDGE AVE
BRONX NY
10467-2403
US

IV. Provider business mailing address

8440 112 ST NW,
EDMONTON ALBERTA
T6G 2B7
CA

V. Phone/Fax

Practice location:
  • Phone: 718-741-2387
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number131827
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: