Healthcare Provider Details

I. General information

NPI: 1679679864
Provider Name (Legal Business Name): ELISABETH JONES HALLER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2006
Last Update Date: 07/08/2007
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 Number15807
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: