Provider Demographics
NPI:1700083813
Name:HADERLIE, MICHAEL JOHN (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JOHN
Last Name:HADERLIE
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 1:4511 ZEBE AVE
Mailing Address - Street 2:
Mailing Address - City:CHUBBUCK
Mailing Address - State:ID
Mailing Address - Zip Code:83202-4707
Mailing Address - Country:US
Mailing Address - Phone:208-904-4780
Mailing Address - Fax:208-904-4832
Practice Address - Street 1:4511 ZEBE AVE
Practice Address - Street 2:
Practice Address - City:CHUBBUCK
Practice Address - State:ID
Practice Address - Zip Code:83202-4707
Practice Address - Country:US
Practice Address - Phone:208-904-4780
Practice Address - Fax:208-904-4832
Is Sole Proprietor?:No
Enumeration Date:2007-07-02
Last Update Date:2022-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-10858207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology