Healthcare Provider Details

I. General information

NPI: 1225207202
Provider Name (Legal Business Name): LARRY JENE HALL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/25/2008
Last Update Date: 02/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2010 OPPORTUNITY LANE
GLIDE OR
97443-9779
US

IV. Provider business mailing address

457 LONE ROCK RD
GLIDE OR
97443-9779
US

V. Phone/Fax

Practice location:
  • Phone: 541-496-4546
  • Fax: 541-496-8538
Mailing address:
  • Phone: 541-496-4546
  • Fax: 541-496-4625

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number6527
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier080796
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: