Provider Demographics
NPI:1396797726
Name:HALLER, FREDERICK R (MD)
Entity type:Individual
Prefix:
First Name:FREDERICK
Middle Name:R
Last Name:HALLER
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 1:740 MCKINLEY AVE
Mailing Address - Street 2:
Mailing Address - City:KELLOGG
Mailing Address - State:ID
Mailing Address - Zip Code:83837-2523
Mailing Address - Country:US
Mailing Address - Phone:208-783-1267
Mailing Address - Fax:208-786-4471
Practice Address - Street 1:740 MCKINLEY AVE
Practice Address - Street 2:
Practice Address - City:KELLOGG
Practice Address - State:ID
Practice Address - Zip Code:83837-2523
Practice Address - Country:US
Practice Address - Phone:208-783-1267
Practice Address - Fax:208-786-4471
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2011-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM3559207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1185830001OtherMEDICARE DMERC
ID080089993OtherRAILROAD MEDICARE
ID002790400Medicaid
B63312Medicare UPIN
1111258Medicare ID - Type Unspecified