Healthcare Provider Details

I. General information

NPI: 1639599541
Provider Name (Legal Business Name): BETHANY MARIE HALL D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/17/2014
Last Update Date: 06/02/2021
Certification Date: 06/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

139 CONFERENCE CENTER WAY STE 113
BRIDGEPORT WV
26330-9147
US

IV. Provider business mailing address

1247 SUNCREST TOWN CENTRE DR
MORGANTOWN WV
26505-1876
US

V. Phone/Fax

Practice location:
  • Phone: 304-599-8000
  • Fax: 304-599-8003
Mailing address:
  • Phone: 304-599-8000
  • Fax: 304-599-8003

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number3045
License Number StateWV
# 3
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number3045
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: