Healthcare Provider Details

I. General information

NPI: 1336975986
Provider Name (Legal Business Name): MARY CLAIRE HALL PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/10/2024
Last Update Date: 01/21/2025
Certification Date: 01/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1520 S LIBERTY DR
BLOOMINGTON IN
47403-5167
US

IV. Provider business mailing address

947 KIRKWOOD DR
EVANSVILLE IN
47715-4564
US

V. Phone/Fax

Practice location:
  • Phone: 812-676-4300
  • Fax:
Mailing address:
  • Phone: 812-499-7051
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10004527B
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10004527A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: