Provider Demographics
NPI:1851363618
Name:HABENICHT, LAURENCE (MD)
Entity Type:Individual
Prefix:
First Name:LAURENCE
Middle Name:
Last Name:HABENICHT
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 1:42 N SAINT JOSEPH AVE
Mailing Address - Street 2:SUITE100
Mailing Address - City:NILES
Mailing Address - State:MI
Mailing Address - Zip Code:49120-2203
Mailing Address - Country:US
Mailing Address - Phone:269-684-6696
Mailing Address - Fax:269-684-5286
Practice Address - Street 1:42 N SAINT JOSEPH AVE
Practice Address - Street 2:SUITE100
Practice Address - City:NILES
Practice Address - State:MI
Practice Address - Zip Code:49120-2203
Practice Address - Country:US
Practice Address - Phone:269-684-6696
Practice Address - Fax:269-684-5286
Is Sole Proprietor?:No
Enumeration Date:2006-02-06
Last Update Date:2016-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301074430174400000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI411815210Medicaid
MI411815210Medicaid
MIMI2051003Medicare PIN