Basic Information
| Provider Information | |||||||||
| NPI: | 1548529415 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HALEY | ||||||||
| FirstName: | TONI | ||||||||
| MiddleName: | ALEXIS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 305 W JACKSON ST | ||||||||
| Address2: | STE 200 | ||||||||
| City: | CARBONDALE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629011474 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6185366621 | ||||||||
| FaxNumber: | 6184531102 | ||||||||
| Practice Location | |||||||||
| Address1: | 305 W JACKSON ST | ||||||||
| Address2: | STE 200 | ||||||||
| City: | CARBONDALE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629011474 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6185366621 | ||||||||
| FaxNumber: | 6184531102 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2012 | ||||||||
| LastUpdateDate: | 11/18/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 125055812 | IL | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 35062 | SC | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 350622 | 05 | SC | MEDICAID |