Provider Demographics
NPI:1750475919
Name:HAEDICKE, GEORGE J (MD)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:J
Last Name:HAEDICKE
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 1:4600 N HABANA AVE
Mailing Address - Street 2:SUITE 22
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33614-7123
Mailing Address - Country:US
Mailing Address - Phone:813-874-7529
Mailing Address - Fax:813-879-1961
Practice Address - Street 1:4600 N HABANA AVE
Practice Address - Street 2:SUITE 22
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33614-7123
Practice Address - Country:US
Practice Address - Phone:813-874-7529
Practice Address - Fax:813-879-1961
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0052210174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE21426Medicare UPIN
FL07836Medicare ID - Type Unspecified