Basic Information
Provider Information | |||||||||
NPI: | 1285991737 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HABIEL | ||||||||
FirstName: | MIRIAM | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 30 BERGEN STREET | ||||||||
Address2: | BUILDING 12 ROOM 1205 | ||||||||
City: | NEWARK | ||||||||
State: | NJ | ||||||||
PostalCode: | 071073000 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9739720037 | ||||||||
FaxNumber: | 9739720743 | ||||||||
Practice Location | |||||||||
Address1: | 90 BERGEN ST FL 6 | ||||||||
Address2: |   | ||||||||
City: | NEWARK | ||||||||
State: | NJ | ||||||||
PostalCode: | 07103 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9739722020 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/20/2012 | ||||||||
LastUpdateDate: | 09/07/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207WX0009X | 25MA10153200 | NJ | Y |   |   |   |   |
ID Information
ID | Type | State | Issuer | Description | 09733049 | 05 | MS |   | MEDICAID | 0637688 | 05 | NJ |   | MEDICAID | 2425196 | 05 | LA |   | MEDICAID |