Provider Demographics
NPI:1053486191
Name:HALLORAN, WALTER HENRY (MD)
Entity Type:Individual
Prefix:DR
First Name:WALTER
Middle Name:HENRY
Last Name:HALLORAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:710 N NILES AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-1924
Mailing Address - Country:US
Mailing Address - Phone:574-647-1610
Mailing Address - Fax:574-237-6069
Practice Address - Street 1:500 ARCADE AVE STE 230
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-2485
Practice Address - Country:US
Practice Address - Phone:574-522-6565
Practice Address - Fax:574-522-5572
Is Sole Proprietor?:No
Enumeration Date:2006-11-22
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01039629208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100103250Medicaid
E86546Medicare UPIN
IN100103250Medicaid
INM400051274Medicare PIN
INM400051274Medicare PIN