Provider Demographics
NPI:1275569592
Name:HALUM, STACEY L (MD)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:L
Last Name:HALUM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7045
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46207-7045
Mailing Address - Country:US
Mailing Address - Phone:317-450-4180
Mailing Address - Fax:317-324-3950
Practice Address - Street 1:1185 W CARMEL DR
Practice Address - Street 2:SUITE D-5
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-8706
Practice Address - Country:US
Practice Address - Phone:317-450-4180
Practice Address - Fax:317-324-3950
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2014-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01061360A207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ININ1585OtherMEDICARE PTAN
IN037690SMedicare PIN
INI07559Medicare UPIN
IN200803060Medicaid