Provider Demographics
NPI:1508029349
Name:CHARLES R HABELOW MD PA
Entity Type:Organization
Organization Name:CHARLES R HABELOW MD PA
Other - Org Name:BAYSIDE MEDICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:R
Authorized Official - Last Name:HABELOW
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:863-494-2293
Mailing Address - Street 1:PO BOX 510310
Mailing Address - Street 2:
Mailing Address - City:PUNTA GORDA
Mailing Address - State:FL
Mailing Address - Zip Code:33951-0310
Mailing Address - Country:US
Mailing Address - Phone:863-494-2293
Mailing Address - Fax:863-494-1520
Practice Address - Street 1:301 N BREVARD AVE
Practice Address - Street 2:SUITE B
Practice Address - City:ARCADIA
Practice Address - State:FL
Practice Address - Zip Code:34266-4501
Practice Address - Country:US
Practice Address - Phone:863-494-2293
Practice Address - Fax:863-494-1520
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-02
Last Update Date:2010-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME49217207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLDN9810OtherRAILROAD MEDICARE B PTAN
FL046638701Medicaid
FL1881601946OtherNPI, TYPE I
FL1508029349OtherNPI , TYPE II
FL1881601946OtherNPI, TYPE I
FL1508029349OtherNPI , TYPE II
FL046638701Medicaid