=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164724274
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HALL MEDICAL, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/22/2010
-----------------------------------------------------
Last Update Date | 02/10/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3190 S WADSWORTH BLVD STE 250
-----------------------------------------------------
City | LAKEWOOD
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80227-4800
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-904-0976
-----------------------------------------------------
Fax | 303-948-5318
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3190 S WADSWORTH BLVD STE 250
-----------------------------------------------------
City | LAKEWOOD
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80227-4800
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-904-0976
-----------------------------------------------------
Fax | 303-948-5318
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JEANNE HALL
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 303-904-0976
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 48824
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------