Provider Demographics
NPI:1477006591
Name:HALLETT, ANDREW (MD)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:HALLETT
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 1:2030 E DAUPHIN ST APT 4
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19125-1548
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4100 LAKE DR SE STE 205
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-8292
Practice Address - Country:US
Practice Address - Phone:616-267-7100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-25
Last Update Date:2024-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT213958208600000X
390200000X
MI4301512108208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program