Provider Demographics
NPI:1811186828
Name:HAACK, MATTHEW RYAN (MD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:RYAN
Last Name:HAACK
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 1:460 NORTHSIDE CHEROKEE BLVD STE 130
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30115-8017
Mailing Address - Country:US
Mailing Address - Phone:678-493-2527
Mailing Address - Fax:678-493-5608
Practice Address - Street 1:460 NORTHSIDE CHEROKEE BLVD STE 130
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30115-8017
Practice Address - Country:US
Practice Address - Phone:678-493-2527
Practice Address - Fax:678-493-5608
Is Sole Proprietor?:No
Enumeration Date:2007-10-16
Last Update Date:2021-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE5643207R00000X
GA070192207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003137391AMedicaid
GA202I298794Medicare PIN