Basic Information
| Provider Information | |||||||||
| NPI: | 1679787535 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HALLER | ||||||||
| FirstName: | SPENCER | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 70 POST OFFICE PARK | ||||||||
| Address2: | |||||||||
| City: | WILBRAHAM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 010951290 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4135987770 | ||||||||
| FaxNumber: | 4135991399 | ||||||||
| Practice Location | |||||||||
| Address1: | 70 POST OFFICE PARK | ||||||||
| Address2: | |||||||||
| City: | WILBRAHAM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 010951290 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4135987770 | ||||||||
| FaxNumber: | 4135991399 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2007 | ||||||||
| LastUpdateDate: | 03/17/2011 | ||||||||
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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 | 222039 | MA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 208000000X | 222039 | MA | N | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 110079183A | 05 | MA | MEDICAID |