=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659686020
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | J. GLENN HAINES, M.D., INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/10/2010
-----------------------------------------------------
Last Update Date | 12/21/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1830 WELLS ST STE 101
-----------------------------------------------------
City | WAILUKU
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96793-2365
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-244-3200
-----------------------------------------------------
Fax | 808-244-9793
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1830 WELLS ST STE 101
-----------------------------------------------------
City | WAILUKU
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96793-2365
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-244-3200
-----------------------------------------------------
Fax | 808-244-9793
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | JAMES GLENN HAINES
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 808-244-3200
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208800000X
-----------------------------------------------------
Taxonomy Name | Urology Physician
-----------------------------------------------------
License Number | 3041
-----------------------------------------------------
License Number State | HI
-----------------------------------------------------