Provider Demographics
NPI:1487607230
Name:HALLER, MARY C (MD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:C
Last Name:HALLER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 CAMPUS DR
Mailing Address - Street 2:
Mailing Address - City:HANCOCK
Mailing Address - State:MI
Mailing Address - Zip Code:49930-1569
Mailing Address - Country:US
Mailing Address - Phone:906-483-1730
Mailing Address - Fax:906-483-1380
Practice Address - Street 1:500 CAMPUS DR
Practice Address - Street 2:
Practice Address - City:HANCOCK
Practice Address - State:MI
Practice Address - Zip Code:49930-1569
Practice Address - Country:US
Practice Address - Phone:906-483-1730
Practice Address - Fax:906-483-1380
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2009-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIMI43048076207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI102928716Medicaid
MIMH048076OtherBLUECROSS STATE ID
MI0829560001OtherMEDICARE DME
0C16002OtherMEDICARE GROUP
MI0C16002016Medicare PIN
MIMH048076OtherBLUECROSS STATE ID