Provider Demographics
NPI:1235122706
Name:HALLERAN, KATHLEEN O (DO)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:O
Last Name:HALLERAN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 E HURON ST APT 1707
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-5900
Mailing Address - Country:US
Mailing Address - Phone:815-337-1953
Mailing Address - Fax:630-321-8750
Practice Address - Street 1:200 E FAIRMAN AVE
Practice Address - Street 2:
Practice Address - City:WATSEKA
Practice Address - State:IL
Practice Address - Zip Code:60970-1644
Practice Address - Country:US
Practice Address - Phone:630-321-8300
Practice Address - Fax:630-321-8750
Is Sole Proprietor?:No
Enumeration Date:2005-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF53967Medicare UPIN
ILK09490Medicare ID - Type Unspecified