Healthcare Provider Details

I. General information

NPI: 1376560839
Provider Name (Legal Business Name): BRUCE LEE HALL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 11/17/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4921 PARKVIEW PL DIV SURG ONCOLOGY, STE 5B
SAINT LOUIS MO
63110-1032
US

IV. Provider business mailing address

660 S EUCLID AVE MSC 8109-37-920
SAINT LOUIS MO
63110-1010
US

V. Phone/Fax

Practice location:
  • Phone: 314-747-0060
  • Fax: 314-747-4871
Mailing address:
  • Phone: 314-454-7224
  • Fax: 877-991-4780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License Number2000161123
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: