Healthcare Provider Details

I. General information

NPI: 1295741197
Provider Name (Legal Business Name): KENNETH H. HALLER DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 12/11/2025
Certification Date: 12/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3600 W BETHEL AVE
MUNCIE IN
47304-5407
US

IV. Provider business mailing address

3600 W BETHEL AVE
MUNCIE IN
47304-5407
US

V. Phone/Fax

Practice location:
  • Phone: 765-284-7738
  • Fax: 765-213-3713
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number02001656A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number02001656A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: