Basic Information
Provider Information
NPI: 1003807025
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: HALLEY
FirstName: JEFFREY
MiddleName: C
NamePrefix: DR.
NameSuffix:  
Credential: MD
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 250 DEBARTOLO PL
Address2: SUITE 2750
City: YOUNGSTOWN
State: OH
PostalCode: 445127004
CountryCode: US
TelephoneNumber: 3307587703
FaxNumber: 3307584930
Practice Location
Address1: 250 DEBARTOLO PL
Address2: SUITE 2750
City: YOUNGSTOWN
State: OH
PostalCode: 445127004
CountryCode: US
TelephoneNumber: 3307587703
FaxNumber: 3307584930
Other Information
ProviderEnumerationDate: 10/31/2005
LastUpdateDate: 01/10/2013
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207R00000X35060338OHN Allopathic & Osteopathic PhysiciansInternal Medicine 
207RC0000XMD420867PAN Allopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
207RC0000X35060338OHY Allopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease

ID Information
IDTypeStateIssuerDescription
016132805OH MEDICAID
0176678505PA MEDICAID


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