Basic Information
| Provider Information | |||||||||
| NPI: | 1396797726 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HALLER | ||||||||
| FirstName: | FREDERICK | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 740 MCKINLEY AVE | ||||||||
| Address2: | |||||||||
| City: | KELLOGG | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838372523 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087831267 | ||||||||
| FaxNumber: | 2087864471 | ||||||||
| Practice Location | |||||||||
| Address1: | 740 MCKINLEY AVE | ||||||||
| Address2: | |||||||||
| City: | KELLOGG | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838372523 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087831267 | ||||||||
| FaxNumber: | 2087864471 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2006 | ||||||||
| LastUpdateDate: | 08/19/2011 | ||||||||
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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 | 207R00000X | M3559 | ID | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1185830001 | 01 | ID | MEDICARE DMERC | OTHER | 080089993 | 01 | ID | RAILROAD MEDICARE | OTHER | 002790400 | 05 | ID | MEDICAID |