=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558342790
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KAREN ELISABETH VON HAAM MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/07/2005
-----------------------------------------------------
Last Update Date | 09/16/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 270 TEATICKET HWY STE 1A
-----------------------------------------------------
City | TEATICKET
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02536-5671
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-540-7423
-----------------------------------------------------
Fax | 508-540-7152
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 270 TEATICKET HWY STE 1A
-----------------------------------------------------
City | TEATICKET
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02536-5671
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-540-7423
-----------------------------------------------------
Fax | 508-540-7152
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 158961
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------