Provider Demographics
NPI:1073524476
Name:HALDEMAN, JOHN GORDON (PT)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:GORDON
Last Name:HALDEMAN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:174 S FREEPORT RD
Mailing Address - Street 2:SUITE 2-C
Mailing Address - City:FREEPORT
Mailing Address - State:ME
Mailing Address - Zip Code:04032-6145
Mailing Address - Country:US
Mailing Address - Phone:207-865-0004
Mailing Address - Fax:207-865-3004
Practice Address - Street 1:174 S FREEPORT RD
Practice Address - Street 2:SUITE 2-C
Practice Address - City:FREEPORT
Practice Address - State:ME
Practice Address - Zip Code:04032-6145
Practice Address - Country:US
Practice Address - Phone:207-865-0004
Practice Address - Fax:207-865-3004
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-10
Last Update Date:2016-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPT794225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME312660099Medicaid
ME3519267OtherCIGNA
ME7938937OtherAETNA
MEAA88121OtherHARVARD PILGRIM
ME098822OtherANTHEM
ME3519267OtherCIGNA
ME7938937OtherAETNA