Provider Demographics
NPI:1174718027
Name:HALLQUIST, ROBERTA RUTH (MD)
Entity type:Individual
Prefix:DR
First Name:ROBERTA
Middle Name:RUTH
Last Name:HALLQUIST
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 1:2812 E SUPERIOR ST
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55812-2345
Mailing Address - Country:US
Mailing Address - Phone:218-724-3024
Mailing Address - Fax:
Practice Address - Street 1:2812 E SUPERIOR ST
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55812-2345
Practice Address - Country:US
Practice Address - Phone:218-724-3024
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-12
Last Update Date:2007-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN454282084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNB533356Medicare UPIN