Healthcare Provider Details

I. General information

NPI: 1104803493
Provider Name (Legal Business Name): BRUCE A HALL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/28/2005
Last Update Date: 04/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 E SHOW LOW LAKE RD
SHOW LOW AZ
85901-7881
US

IV. Provider business mailing address

300 W WHITE MOUNTAIN BLVD STE D
LAKESIDE AZ
85929-7014
US

V. Phone/Fax

Practice location:
  • Phone: 928-537-4375
  • Fax:
Mailing address:
  • Phone: 928-368-4547
  • Fax: 928-368-4527

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number25444
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: