Provider Demographics
NPI:1053338855
Name:HALEY, SALLY (MD)
Entity type:Individual
Prefix:DR
First Name:SALLY
Middle Name:
Last Name:HALEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:93 CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:ME
Mailing Address - Zip Code:04011-7306
Mailing Address - Country:US
Mailing Address - Phone:207-798-5907
Mailing Address - Fax:207-729-5757
Practice Address - Street 1:93 CHURCH RD
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:ME
Practice Address - Zip Code:04011-7306
Practice Address - Country:US
Practice Address - Phone:207-798-5907
Practice Address - Fax:207-729-5757
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME013740208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME013740OtherMEDICAL LICENSE
ME025883OtherANTHEM
MEG99499Medicare UPIN