=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861753485
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JASON MARK HABECK MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/30/2012
-----------------------------------------------------
Last Update Date | 06/01/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13020 N TELECOM PKWY
-----------------------------------------------------
City | TEMPLE TERRACE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33637-0925
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-978-9700
-----------------------------------------------------
Fax | 813-558-6187
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 123 HOSPITAL DR STE 1008
-----------------------------------------------------
City | WATERTOWN
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53098-3320
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-206-6500
-----------------------------------------------------
Fax | 920-261-4013
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number | 4301100883
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number | 4301100883
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number | ME130378
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------