Healthcare Provider Details

I. General information

NPI: 1578569612
Provider Name (Legal Business Name): JOHN R HALL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2005
Last Update Date: 08/23/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

321 W PROMENADE ST
MEXICO MO
65265-2719
US

IV. Provider business mailing address

321 W PROMENADE ST
MEXICO MO
65265-2719
US

V. Phone/Fax

Practice location:
  • Phone: 573-582-1234
  • Fax: 573-582-1212
Mailing address:
  • Phone: 573-582-1234
  • Fax: 573-582-1212

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number110843
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: