Organization
CEDAR LAKE PEDIATRIC CLINIC PLLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. LISA J HALLER MD (OWNER)
(228) 248-2572
Entity
Organization
Contact information
Practice address
1721 MEDICAL PARK DR STE 200, BILOXI, MS 39532-2105
(228) 248-2572
(228) 396-0687
Mailing address
PO BOX 8873, BILOXI, MS 39535-8873
(228) 248-2572
(228) 396-0687
Taxonomy
Speciality
Code
Description
License number
State
208000000X
Pediatrics Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
09479561
—
MS
Enumeration date
11/13/2006
Last updated
07/12/2007
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