Healthcare Provider Details

I. General information

NPI: 1548479751
Provider Name (Legal Business Name): DANIEL M HALLAM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2007
Last Update Date: 05/22/2020
Certification Date: 05/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 W WALNUT ST
JACKSONVILLE IL
62650-1136
US

IV. Provider business mailing address

1025 S 6TH ST
SPRINGFIELD IL
62703-2403
US

V. Phone/Fax

Practice location:
  • Phone: 217-528-7541
  • Fax: 217-528-7541
Mailing address:
  • Phone: 217-528-7541
  • Fax: 217-528-7541

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number036125699
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License Number036125699
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: