Provider Demographics
NPI:1952339814
Name:HALLER, ROBERT W (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:W
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 1:2845 GREENBRIER RD
Mailing Address - Street 2:PO BOX 8900
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54308-8900
Mailing Address - Country:US
Mailing Address - Phone:920-288-4930
Mailing Address - Fax:920-288-4941
Practice Address - Street 1:2845 GREENBRIER RD
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311-6519
Practice Address - Country:US
Practice Address - Phone:920-288-4930
Practice Address - Fax:920-288-4941
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2008-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI444442085B0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI300129574OtherRAILROAD
WI34217800Medicaid
MI104395500Medicaid
WIG04145Medicare UPIN
WI34217800Medicaid