Healthcare Provider Details

I. General information

NPI: 1003810656
Provider Name (Legal Business Name): RONALD R HALL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2005
Last Update Date: 06/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1717 S CALHOUN ST
FORT WAYNE IN
46802-5257
US

IV. Provider business mailing address

1717 S CALHOUN ST
FORT WAYNE IN
46802-5257
US

V. Phone/Fax

Practice location:
  • Phone: 260-458-2641
  • Fax: 260-969-0007
Mailing address:
  • Phone: 260-458-2641
  • Fax: 260-969-0007

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number01022184A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: