Provider Demographics
NPI:1447466446
Name:HALLERBACH, MARCO (MD)
Entity type:Individual
Prefix:
First Name:MARCO
Middle Name:
Last Name:HALLERBACH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1514 VERNON RD
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30240-4131
Mailing Address - Country:US
Mailing Address - Phone:706-882-1411
Mailing Address - Fax:
Practice Address - Street 1:1514 VERNON RD
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240-4131
Practice Address - Country:US
Practice Address - Phone:706-882-1411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2016-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME103776207R00000X
GA066499207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLBY497YMedicare PIN