Healthcare Provider Details

I. General information

NPI: 1407853146
Provider Name (Legal Business Name): ANDREA LEIGH HALLER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ANDREA L MARCUS

II. Dates (important events)

Enumeration Date: 07/07/2005
Last Update Date: 09/13/2023
Certification Date: 09/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7956 W JEFFERSON BLVD
FORT WAYNE IN
46804-4140
US

IV. Provider business mailing address

250 N SHADELAND AVE
INDIANAPOLIS IN
46219-4959
US

V. Phone/Fax

Practice location:
  • Phone: 260-436-2416
  • Fax: 260-436-9662
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084S0012X
TaxonomySleep Medicine (Psychiatry & Neurology) Physician
License Number01053486A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number01053486A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: