Provider Demographics
NPI:1043342074
Name:BRADLEY E HABERMEHL OD PC
Entity Type:Organization
Organization Name:BRADLEY E HABERMEHL OD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:HABERMEHL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:810-736-0710
Mailing Address - Street 1:2284 RIDGEMOOR CT
Mailing Address - Street 2:
Mailing Address - City:BURTON
Mailing Address - State:MI
Mailing Address - Zip Code:48509-1391
Mailing Address - Country:US
Mailing Address - Phone:810-736-0710
Mailing Address - Fax:810-736-2713
Practice Address - Street 1:4091 RICHFIELD RD
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48506-2033
Practice Address - Country:US
Practice Address - Phone:810-736-0710
Practice Address - Fax:810-736-2713
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-13
Last Update Date:2008-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003225152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI900B565300OtherBCBS
MI4114020001Medicare NSC
MI0P51720Medicare PIN
MI900B565300OtherBCBS