=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689996563
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TERESA A. HABACKER, M.D.,P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/19/2010
-----------------------------------------------------
Last Update Date | 05/09/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5954 ROUTE 25A
-----------------------------------------------------
City | WADING RIVER
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11792-2001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-473-4263
-----------------------------------------------------
Fax | 631-473-4260
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5954 ROUTE 25A
-----------------------------------------------------
City | WADING RIVER
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11792-2001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-473-4263
-----------------------------------------------------
Fax | 631-473-4260
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. TERESA AIMEE HABACKER
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 631-473-4263
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number | 184539-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------