Provider Demographics
NPI:1942279179
Name:HALDERMAN, JOHN (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:HALDERMAN
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 1:3200 GRANT STREET
Mailing Address - Street 2:ATTN ACCOUNTING DEPARTMENT
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201
Mailing Address - Country:US
Mailing Address - Phone:847-492-4871
Mailing Address - Fax:847-570-3426
Practice Address - Street 1:3200 GRANT STREET
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201
Practice Address - Country:US
Practice Address - Phone:847-492-4828
Practice Address - Fax:847-492-4810
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360500552084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL211076Medicare ID - Type UnspecifiedGROUP NUMBER
ILK16226Medicare ID - Type Unspecified
C42250Medicare UPIN
ILK15271Medicare ID - Type Unspecified
210708Medicare ID - Type UnspecifiedGROUP NUMBER
IL260045662Medicare ID - Type UnspecifiedRAIL ROAD