Basic Information
| Provider Information | |||||||||
| NPI: | 1639161748 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HALTER | ||||||||
| FirstName: | PAUL | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | III | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 129 | ||||||||
| Address2: | |||||||||
| City: | GREENFIELD | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461400129 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3174686270 | ||||||||
| FaxNumber: | 3174686268 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 E BOYD AVE STE 250 | ||||||||
| Address2: | |||||||||
| City: | GREENFIELD | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461402845 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3174674500 | ||||||||
| FaxNumber: | 3174776321 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2005 | ||||||||
| LastUpdateDate: | 10/08/2010 | ||||||||
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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 | 208000000X | 01059547A | IN | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 000000341265 | 01 | IN | ANTHEM PIN # | OTHER | 200303630 | 05 | IN | MEDICAID | 200311740E | 01 | MCD GRP# & LOCATION | OTHER | 7199596 | 01 | IN | AETNA PIN # | OTHER |