Healthcare Provider Details

I. General information

NPI: 1659590040
Provider Name (Legal Business Name): MATTHEW ALAN HALL P.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

328 S WOODSCREST DR
BLOOMINGTON IN
47401-5314
US

IV. Provider business mailing address

1052 JENNIFER DR
BLOOMINGTON IN
47401-9755
US

V. Phone/Fax

Practice location:
  • Phone: 812-353-3278
  • Fax: 812-353-3370
Mailing address:
  • Phone: 812-339-0366
  • Fax: 812-339-0366

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number05007014A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: