Basic Information
| Provider Information | |||||||||
| NPI: | 1235108937 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HALLER | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 FODEN ROAD W | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | SOUTH PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 04106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078280361 | ||||||||
| FaxNumber: | 2078741483 | ||||||||
| Practice Location | |||||||||
| Address1: | 259 MAIN STREET | ||||||||
| Address2: | |||||||||
| City: | YARMOUTH | ||||||||
| State: | ME | ||||||||
| PostalCode: | 04096 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078469013 | ||||||||
| FaxNumber: | 2075238586 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/15/2006 | ||||||||
| LastUpdateDate: | 10/28/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 013405 | ME | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 014279 | 01 | ANTHEM | OTHER | 0797926 | 01 | AETNA | OTHER | 278010099 | 05 | ME | MEDICAID |