Provider Demographics
NPI:1295741197
Name:HALLER, KENNETH H (DO)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:H
Last Name:HALLER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3600 W BETHEL AVE
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47304-5407
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3600 W BETHEL AVE
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47304-5407
Practice Address - Country:US
Practice Address - Phone:765-284-7738
Practice Address - Fax:765-213-3713
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2025-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02001656A207Q00000X, 207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000087018OtherANTHEM PIN
IN200064610Medicaid
IN250009136OtherRAILROAD MEDICARE
IN250009136OtherRAILROAD MEDICARE
INF98135Medicare UPIN