Basic Information
| Provider Information | |||||||||
| NPI: | 1629064803 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HABERKAMP | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9500 EUCLID AVE | ||||||||
| Address2: | DESK A71 | ||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441950001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2164446696 | ||||||||
| FaxNumber: | 2164459409 | ||||||||
| Practice Location | |||||||||
| Address1: | 9500 EUCLID AVE | ||||||||
| Address2: | DESK A71 | ||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441950001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2164446696 | ||||||||
| FaxNumber: | 2164459409 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/23/2005 | ||||||||
| LastUpdateDate: | 10/14/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | 036072778 | IL | Y | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | P00160607 | 01 | IL | RAILROAD MEDICARE | OTHER | 610797100 | 01 | IL | WORKERS COMPENSATION | OTHER | 3113553 | 05 | OH | MEDICAID | 1627261 | 01 | IL | BCBS PROVIDER ID | OTHER |