Provider Demographics
NPI:1881647048
Name:HAEBICH, JOHN R (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:R
Last Name:HAEBICH
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 1:401 W LAKE ST
Mailing Address - Street 2:FRNT 1
Mailing Address - City:NORTHLAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60164-2438
Mailing Address - Country:US
Mailing Address - Phone:773-282-6188
Mailing Address - Fax:773-282-7389
Practice Address - Street 1:3825 N CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60634-2719
Practice Address - Country:US
Practice Address - Phone:773-282-6188
Practice Address - Fax:773-282-7389
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2018-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036069235207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036069235Medicaid
ILL67276Medicare ID - Type Unspecified
ILC42305Medicare UPIN