Provider Demographics
NPI:1215238225
Name:DR GERARD O'HALLORAN ENT & FACIAL PLASTIC SURGERY PA
Entity type:Organization
Organization Name:DR GERARD O'HALLORAN ENT & FACIAL PLASTIC SURGERY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GERARD
Authorized Official - Middle Name:L
Authorized Official - Last Name:O'HALLORAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:612-590-0175
Mailing Address - Street 1:5133 SHERIDAN AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55410-2238
Mailing Address - Country:US
Mailing Address - Phone:612-590-0175
Mailing Address - Fax:651-493-0968
Practice Address - Street 1:1645 LYNDALE AVE N
Practice Address - Street 2:SUITE 3
Practice Address - City:FARIBAULT
Practice Address - State:MN
Practice Address - Zip Code:55021-2934
Practice Address - Country:US
Practice Address - Phone:612-590-0175
Practice Address - Fax:651-493-0968
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-07
Last Update Date:2010-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN30984207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN040000375Medicaid