Healthcare Provider Details

I. General information

NPI: 1689837775
Provider Name (Legal Business Name): KEVIN MICHAEL HALL PA-AA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2008
Last Update Date: 10/03/2024
Certification Date: 10/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35 COLLIER RD NW STE 775
ATLANTA GA
30309-1608
US

IV. Provider business mailing address

1599 EASTLAND RD SE
ATLANTA GA
30316-3410
US

V. Phone/Fax

Practice location:
  • Phone: 404-605-7100
  • Fax:
Mailing address:
  • Phone:
  • Fax: 816-932-9089

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number5874
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA10004213
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5874
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License Number2020020930
License Number StateMO
# 5
Primary TaxonomyY
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License Number5874
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: