Basic Information
| Provider Information | |||||||||
| NPI: | 1831170935 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HASELHORST | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | JOHN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5777 N 78TH PL | ||||||||
| Address2: | |||||||||
| City: | SCOTTSDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852506170 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4809479682 | ||||||||
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| Practice Location | |||||||||
| Address1: | 13677 W MCDOWELL RD | ||||||||
| Address2: | |||||||||
| City: | GOODYEAR | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853382618 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6238821500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2005 | ||||||||
| LastUpdateDate: | 09/28/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 25725 | AZ | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 208D00000X | 25725 | AZ | Y | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | AW1436 | 01 | AZ | HEALTHNET GROUP | OTHER | 860373636 | 01 | AZ | HUMANA-GROUP # | OTHER | 453051001 | 01 | AZ | GROUP HEALTH GROUP | OTHER | AZ0728670 | 01 | AZ | BLUE CROSS BLUE SHIELD-GR | OTHER | 3981220 | 01 | AZ | EVERCARE GROUP | OTHER | 420886 | 05 | AZ | MEDICAID |