Provider Demographics
NPI:1215209903
Name:STEPHEN A. HABENER, M.D., INC., P.S.
Entity Type:Organization
Organization Name:STEPHEN A. HABENER, M.D., INC., P.S.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MISS
Authorized Official - First Name:TIA
Authorized Official - Middle Name:L
Authorized Official - Last Name:SMART
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-373-2571
Mailing Address - Street 1:2635 WHEATON WAY
Mailing Address - Street 2:
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98310-3318
Mailing Address - Country:US
Mailing Address - Phone:360-373-2571
Mailing Address - Fax:360-479-4970
Practice Address - Street 1:2635 WHEATON WAY
Practice Address - Street 2:
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98310-3318
Practice Address - Country:US
Practice Address - Phone:360-373-2571
Practice Address - Fax:360-479-4970
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-27
Last Update Date:2012-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00011593174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1340306Medicaid
WAA06927OtherUPIN
WAG000200161Medicare PIN