Healthcare Provider Details

I. General information

NPI: 1497826044
Provider Name (Legal Business Name): CEDAR LAKE PEDIATRIC CLINIC PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/13/2006
Last Update Date: 07/12/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1721 MEDICAL PARK DR STE 200
BILOXI MS
39532-2105
US

IV. Provider business mailing address

PO BOX 8873
BILOXI MS
39535-8873
US

V. Phone/Fax

Practice location:
  • Phone: 228-248-2572
  • Fax: 228-396-0687
Mailing address:
  • Phone: 228-248-2572
  • Fax: 228-396-0687

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. LISA J HALLER
Title or Position: OWNER
Credential: MD
Phone: 228-248-2572