Provider Demographics
NPI:1316273519
Name:HAIDSIAK, MICHAEL B (PT)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:B
Last Name:HAIDSIAK
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:465 42ND AVE STE 140
Mailing Address - Street 2:
Mailing Address - City:EAST MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61244-4004
Mailing Address - Country:US
Mailing Address - Phone:309-779-3490
Mailing Address - Fax:309-779-5615
Practice Address - Street 1:465 42ND AVE STE 140
Practice Address - Street 2:
Practice Address - City:EAST MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61244-4004
Practice Address - Country:US
Practice Address - Phone:309-779-3490
Practice Address - Fax:309-779-5615
Is Sole Proprietor?:No
Enumeration Date:2009-10-22
Last Update Date:2009-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070009596225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist