=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760570592
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELLEN ANNETTE HALL MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/10/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4855 SW WESTERN AVE
-----------------------------------------------------
City | BEAVERTON
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97005-3460
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-643-7565
-----------------------------------------------------
Fax | 503-626-4415
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4855 SW WESTERN AVE
-----------------------------------------------------
City | BEAVERTON
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97005-3460
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-643-7565
-----------------------------------------------------
Fax | 503-626-4415
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | MD15640
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------