Provider Demographics
NPI:1497826044
Name:CEDAR LAKE PEDIATRIC CLINIC PLLC
Entity Type:Organization
Organization Name:CEDAR LAKE PEDIATRIC CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LISA
Authorized Official - Middle Name:J
Authorized Official - Last Name:HALLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:228-248-2572
Mailing Address - Street 1:PO BOX 8873
Mailing Address - Street 2:
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39535-8873
Mailing Address - Country:US
Mailing Address - Phone:228-248-2572
Mailing Address - Fax:228-396-0687
Practice Address - Street 1:1721 MEDICAL PARK DR STE 200
Practice Address - Street 2:
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39532-2105
Practice Address - Country:US
Practice Address - Phone:228-248-2572
Practice Address - Fax:228-396-0687
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-13
Last Update Date:2007-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09479561Medicaid
MSC03428Medicare ID - Type UnspecifiedGROUP MCARE NUMBER