Provider Demographics
NPI:1912971508
Name:HALLBERG, JOHN ANDREW (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:ANDREW
Last Name:HALLBERG
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 1:194 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FORT KENT
Mailing Address - State:ME
Mailing Address - Zip Code:04743-1428
Mailing Address - Country:US
Mailing Address - Phone:207-834-5912
Mailing Address - Fax:207-834-5914
Practice Address - Street 1:194 E MAIN ST
Practice Address - Street 2:
Practice Address - City:FORT KENT
Practice Address - State:ME
Practice Address - Zip Code:04743-1428
Practice Address - Country:US
Practice Address - Phone:207-834-5912
Practice Address - Fax:207-834-5914
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2013-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT029044207X00000X
RIMD07302207X00000X
WV22726207X00000X
NC2010-00313207X00000X
METD131075207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC156VWOtherBCBSNC
WV3810008679Medicaid
NC2075645Medicare PIN
4203451Medicare PIN
C89752Medicare UPIN
RI209021999Medicare ID - Type Unspecified
WV3810008679Medicaid