Healthcare Provider Details

I. General information

NPI: 1841231610
Provider Name (Legal Business Name): SHELLY L. HALL M.D., P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4611 US HIGHWAY 17 SUITE 2
ORANGE PARK FL
32003-8245
US

IV. Provider business mailing address

4611 US HIGHWAY 17 SUITE 2
ORANGE PARK FL
32003-8245
US

V. Phone/Fax

Practice location:
  • Phone: 904-264-4333
  • Fax: 904-264-4301
Mailing address:
  • Phone: 904-264-4333
  • Fax: 904-264-4301

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME0061916
License Number StateFL

VIII. Authorized Official

Name: DR. SHELLY L. HALL
Title or Position: PRESIDENT
Credential: MD
Phone: 904-264-4333