Basic Information
| Provider Information | |||||||||
| NPI: | 1225024615 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALLER | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | MELANIE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HALUSZKA | ||||||||
| OtherFirstName: | MARY | ||||||||
| OtherMiddleName: | MELANIE | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 97 | ||||||||
| Address2: | |||||||||
| City: | OLNEY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 624500097 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6183957340 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1200 N EAST ST | ||||||||
| Address2: | |||||||||
| City: | OLNEY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 624502432 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6183955222 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2005 | ||||||||
| LastUpdateDate: | 10/05/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 036119328 | IL | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 036119328 | 05 | IL | MEDICAID |