Provider Demographics
NPI:1447267729
Name:HASLAM, J MATTHEW (MD)
Entity type:Individual
Prefix:
First Name:J
Middle Name:MATTHEW
Last Name:HASLAM
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 1:1275 SAGE ST
Mailing Address - Street 2:
Mailing Address - City:GERING
Mailing Address - State:NE
Mailing Address - Zip Code:69341-3227
Mailing Address - Country:US
Mailing Address - Phone:308-436-2101
Mailing Address - Fax:308-436-3681
Practice Address - Street 1:1275 SAGE ST
Practice Address - Street 2:
Practice Address - City:GERING
Practice Address - State:NE
Practice Address - Zip Code:69341-3227
Practice Address - Country:US
Practice Address - Phone:308-436-2101
Practice Address - Fax:308-436-3681
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2007-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE16128207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
16128OtherSTATE LICENSE
080074005OtherMEDICARE RAILROAD
283821AOtherRURAL HEALTH
272636Medicare PIN
266062Medicare PIN
080074005OtherMEDICARE RAILROAD