Basic Information
| Provider Information | |||||||||
| NPI: | 1306804190 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HALLIGAN | ||||||||
| FirstName: | SEAN | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 145 FOREST AVE | ||||||||
| Address2: | |||||||||
| City: | STATEN ISLAND | ||||||||
| State: | NY | ||||||||
| PostalCode: | 103012715 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5854694880 | ||||||||
| FaxNumber: | 5853364845 | ||||||||
| Practice Location | |||||||||
| Address1: | 145 FOREST AVE | ||||||||
| Address2: | |||||||||
| City: | STATEN ISLAND | ||||||||
| State: | NY | ||||||||
| PostalCode: | 103012715 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5854694880 | ||||||||
| FaxNumber: | 5853364845 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2006 | ||||||||
| LastUpdateDate: | 05/04/2019 | ||||||||
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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 | 209013 | NY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00355266 | 05 | NY | MEDICAID |