Provider Demographics
NPI:1568434942
Name:HALLORAN, FRED J (MD)
Entity Type:Individual
Prefix:
First Name:FRED
Middle Name:J
Last Name:HALLORAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11904 OAK CREEK PKWY
Mailing Address - Street 2:
Mailing Address - City:HUNTLEY
Mailing Address - State:IL
Mailing Address - Zip Code:60142-6728
Mailing Address - Country:US
Mailing Address - Phone:847-506-1478
Mailing Address - Fax:224-858-4001
Practice Address - Street 1:11904 OAK CREEK PKWY
Practice Address - Street 2:
Practice Address - City:HUNTLEY
Practice Address - State:IL
Practice Address - Zip Code:60142-6728
Practice Address - Country:US
Practice Address - Phone:847-506-1478
Practice Address - Fax:224-858-4001
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-01
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036081972207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036081972Medicaid
IL368880OtherMEDICARE PTAN
IL036081972Medicaid
ILL37340Medicare PIN