Provider Demographics
NPI:1154405009
Name:HAEGERT, STANLEY (MD)
Entity type:Individual
Prefix:
First Name:STANLEY
Middle Name:
Last Name:HAEGERT
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 1:1310 WISCONSIN ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:GRAND HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49417-2472
Mailing Address - Country:US
Mailing Address - Phone:616-847-5604
Mailing Address - Fax:616-847-5608
Practice Address - Street 1:1310 WISCONSIN ST
Practice Address - Street 2:SUITE 103
Practice Address - City:GRAND HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49417-2472
Practice Address - Country:US
Practice Address - Phone:616-846-2640
Practice Address - Fax:616-846-3110
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2019-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN64514207Q00000X
WY11742C207Q00000X
WAMD60893797207Q00000X
CAG158510207Q00000X
IL036147324207Q00000X
NV18348207Q00000X
IAMD-46030207Q00000X
SD11380207Q00000X
MI4301407097207Q00000X
COCDRH.0061038207Q00000X
AZ57243207Q00000X
IDMC-0098207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MII01538Medicare UPIN