Provider Demographics
NPI:1851644082
Name:CARL HALLER, MD, A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:CARL HALLER, MD, A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, SOLE OWNER OF CORPORATIO
Authorized Official - Prefix:DR
Authorized Official - First Name:CARL
Authorized Official - Middle Name:
Authorized Official - Last Name:HALLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:916-483-3437
Mailing Address - Street 1:3609 MISSION AVE., STE D
Mailing Address - Street 2:
Mailing Address - City:CARMICHAEL (COUNTY OF SACRAMENTO)
Mailing Address - State:CA
Mailing Address - Zip Code:95608-2955
Mailing Address - Country:US
Mailing Address - Phone:916-483-3437
Mailing Address - Fax:916-483-3218
Practice Address - Street 1:3609 MISSION AVE., STE D
Practice Address - Street 2:
Practice Address - City:CARMICHAEL (COUNTY OF SACRAMENTO)
Practice Address - State:CA
Practice Address - Zip Code:95608-2955
Practice Address - Country:US
Practice Address - Phone:916-483-3437
Practice Address - Fax:916-483-3218
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-25
Last Update Date:2012-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACALIFORNIAG9581207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA136655214301Medicaid
CA000G95810Medicare Oscar/Certification
CA136655214301Medicaid