Provider Demographics
NPI:1467478164
Name:HALVERSON, ELLEN J (MD)
Entity Type:Individual
Prefix:DR
First Name:ELLEN
Middle Name:J
Last Name:HALVERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4105
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-4105
Mailing Address - Country:US
Mailing Address - Phone:866-907-1068
Mailing Address - Fax:425-917-9141
Practice Address - Street 1:2250 S WOODWORTH LOOP
Practice Address - Street 2:SUITE 202
Practice Address - City:PALMER
Practice Address - State:AK
Practice Address - Zip Code:99645-7412
Practice Address - Country:US
Practice Address - Phone:907-761-5800
Practice Address - Fax:907-761-5801
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK41522084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1010614Medicaid
AK1010614Medicaid
E86543Medicare UPIN
AKMDG023OtherMEDICAID MD GROUP #
AK17091Medicaid
E86543Medicare UPIN
151759Medicare ID - Type Unspecified
AKE86543Medicare UPIN