Provider Demographics
NPI:1245204858
Name:HALLER, LISA (MD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:
Last Name:HALLER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2514 S 102ND ST
Mailing Address - Street 2:SUITE 120
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53227-2142
Mailing Address - Country:US
Mailing Address - Phone:414-777-5200
Mailing Address - Fax:414-777-5210
Practice Address - Street 1:5650 N GREEN BAY AVE STE 210
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:WI
Practice Address - Zip Code:53209-4447
Practice Address - Country:US
Practice Address - Phone:414-431-5971
Practice Address - Fax:414-434-0354
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI43090207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34072700Medicaid
001201079Medicare PIN
WIH17166Medicare UPIN