Provider Demographics
NPI:1447340559
Name:HAECK, PHILLIP CARL (MD)
Entity type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:CARL
Last Name:HAECK
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 1:901 BOREN AVE
Mailing Address - Street 2:SUITE 1650
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98104-3595
Mailing Address - Country:US
Mailing Address - Phone:206-464-0873
Mailing Address - Fax:206-467-7351
Practice Address - Street 1:901 BOREN AVE
Practice Address - Street 2:SUITE 1650
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98104-3595
Practice Address - Country:US
Practice Address - Phone:206-464-0873
Practice Address - Fax:206-467-7351
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00020989174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAA06716Medicare UPIN