Healthcare Provider Details

I. General information

NPI: 1922012194
Provider Name (Legal Business Name): TIMOTHY S HALL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 08/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1025 MICHIGAN AVE SUITE 115
LOGANSPORT IN
46947-1665
US

IV. Provider business mailing address

1025 MICHIGAN AVE SUITE 115
LOGANSPORT IN
46947-1665
US

V. Phone/Fax

Practice location:
  • Phone: 574-722-3566
  • Fax: 574-753-6118
Mailing address:
  • Phone: 574-722-3566
  • Fax: 574-753-6118

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number9600933
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number01072086A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: