Provider Demographics
NPI:1679633994
Name:HAINES, PHILIP C (MD)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:C
Last Name:HAINES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1011 PARCHMENT DR SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-3664
Mailing Address - Country:US
Mailing Address - Phone:616-957-2200
Mailing Address - Fax:616-957-4274
Practice Address - Street 1:1011 PARCHMENT DR SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-3664
Practice Address - Country:US
Practice Address - Phone:616-957-2200
Practice Address - Fax:616-957-4274
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-08
Last Update Date:2011-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010339712084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI103028918Medicaid
383145416OtherTAX I.D. NUMBER
MI0410081Medicare ID - Type Unspecified
MI103028918Medicaid