Healthcare Provider Details

I. General information

NPI: 1912971508
Provider Name (Legal Business Name): JOHN ANDREW HALLBERG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2006
Last Update Date: 06/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

194 E MAIN ST
FORT KENT ME
04743-1428
US

IV. Provider business mailing address

194 E MAIN ST
FORT KENT ME
04743-1428
US

V. Phone/Fax

Practice location:
  • Phone: 207-834-5912
  • Fax: 207-834-5914
Mailing address:
  • Phone: 207-834-5912
  • Fax: 207-834-5914

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number029044
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberMD07302
License Number StateRI
# 3
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number22726
License Number StateWV
# 4
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number2010-00313
License Number StateNC
# 5
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberTD131075
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: