Provider Demographics
NPI:1366460917
Name:HALEY, PHILIP HARDWICK (MD)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:HARDWICK
Last Name:HALEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1017 W RIVER PKWY
Mailing Address - Street 2:
Mailing Address - City:CHAMPLIN
Mailing Address - State:MN
Mailing Address - Zip Code:55316-1039
Mailing Address - Country:US
Mailing Address - Phone:763-421-3088
Mailing Address - Fax:763-421-3088
Practice Address - Street 1:8290 UNIVERSITY AVE NE
Practice Address - Street 2:SUITE 200
Practice Address - City:FRIDLEY
Practice Address - State:MN
Practice Address - Zip Code:55432-1847
Practice Address - Country:US
Practice Address - Phone:763-786-9543
Practice Address - Fax:763-786-3320
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2008-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN19477207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN636283400Medicaid
MN636283400Medicaid
MNA94722Medicare UPIN