Provider Demographics
NPI:1922047810
Name:HAEDICKE, KAY (MD)
Entity Type:Individual
Prefix:
First Name:KAY
Middle Name:
Last Name:HAEDICKE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 LUNAR DRIVE
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:CT
Mailing Address - Zip Code:06525
Mailing Address - Country:US
Mailing Address - Phone:203-389-7504
Mailing Address - Fax:203-389-8854
Practice Address - Street 1:111 GOOSE LANE
Practice Address - Street 2:SUITE 1300
Practice Address - City:GUILFORD
Practice Address - State:CT
Practice Address - Zip Code:06437
Practice Address - Country:US
Practice Address - Phone:203-453-9192
Practice Address - Fax:203-453-0875
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2013-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT026723207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001267237Medicaid
CTE45121Medicare UPIN
CT830000174Medicare PIN
CT001267237Medicaid