Provider Demographics
NPI:1538501994
Name:HAYDEL MEDICAL & PAIN CENTER LLC
Entity Type:Organization
Organization Name:HAYDEL MEDICAL & PAIN CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:
Authorized Official - First Name:KARL
Authorized Official - Middle Name:G
Authorized Official - Last Name:HAYDEL
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:888-836-7015
Mailing Address - Street 1:1690 DUNLAWTON AVE
Mailing Address - Street 2:SUITE 130
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32127-8979
Mailing Address - Country:US
Mailing Address - Phone:888-836-7015
Mailing Address - Fax:
Practice Address - Street 1:1057 PAUL MAILLARD RD
Practice Address - Street 2:
Practice Address - City:LULING
Practice Address - State:LA
Practice Address - Zip Code:70070-4349
Practice Address - Country:US
Practice Address - Phone:888-836-7015
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-25
Last Update Date:2014-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA019061207L00000X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty