Provider Demographics
NPI:1235629742
Name:ROBERT W HAEBERLEIN JR MD PA
Entity Type:Organization
Organization Name:ROBERT W HAEBERLEIN JR MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHELLIE
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:WELLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-942-4653
Mailing Address - Street 1:700 MOUNT HOPE AVE STE 601
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-5674
Mailing Address - Country:US
Mailing Address - Phone:207-942-4653
Mailing Address - Fax:207-990-4795
Practice Address - Street 1:700 MOUNT HOPE AVE STE 601
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-5674
Practice Address - Country:US
Practice Address - Phone:207-942-4653
Practice Address - Fax:207-990-4795
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ROBERT W HAEBERLEIN MD JR PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-05-10
Last Update Date:2018-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMD9794207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty