Healthcare Provider Details

I. General information

NPI: 1821785858
Provider Name (Legal Business Name): ROBERT HALDEMAN JR. BSN, RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/19/2023
Last Update Date: 04/19/2023
Certification Date: 04/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4721 WAYNE RTE E
GREENVILLE MO
63944-8943
US

IV. Provider business mailing address

1500 N WESTWOOD BLVD
POPLAR BLUFF MO
63901-3318
US

V. Phone/Fax

Practice location:
  • Phone: 573-778-6955
  • Fax:
Mailing address:
  • Phone: 573-686-4151
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number2000160942
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: