Basic Information
Provider Information | |||||||||
NPI: | 1467424218 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HABENICHT | ||||||||
FirstName: | DEBORAH | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 6416 DEANS HILL ROAD | ||||||||
Address2: |   | ||||||||
City: | BERRIEN SPRINGS | ||||||||
State: | MI | ||||||||
PostalCode: | 491209750 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2694717741 | ||||||||
FaxNumber: | 2694711581 | ||||||||
Practice Location | |||||||||
Address1: | 42 NORTH ST.JOSEPH AVE | ||||||||
Address2: | SUITE 300 | ||||||||
City: | NILES | ||||||||
State: | MI | ||||||||
PostalCode: | 491202296 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2696872910 | ||||||||
FaxNumber: | 2696878770 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/06/2006 | ||||||||
LastUpdateDate: | 05/02/2014 | ||||||||
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 | 174400000X | 4301074195 | MI | N |   | Other Service Providers | Specialist |   | 207Y00000X | 4301074195 | MI | Y |   | Allopathic & Osteopathic Physicians | Otolaryngology |   |
ID Information
ID | Type | State | Issuer | Description | 0401111441 | 01 | MI | BCBS | OTHER | AH1427447 | 01 | MI | DEA | OTHER | 451503610 | 05 | MI |   | MEDICAID |