MEDICARE: DR. ELI R HALLAL M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	01025361A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	000000042312	OTHER	IN	ANTHEM
3	351359575	OTHER	IN	COMMERCIAL
4	I001704	OTHER	IN	TRICARE /CHAMPUS
5	35135957500	OTHER	OH	OHIO BUREAU OF WORKERS' C

General Provider Information

NPI Number	:	1083614416
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ELI R HALLAL M.D.

Provider Business Mailing Address
First Line	:	1964 STATE ST
Second Line	:	SUITE 100
City	:	NEW ALBANY
State	:	IN
Zip	:	47150-4934
Country	:	US
Telephone Number	:	812-948-1641
Fax Number	:	812-941-0438

Provider Business Practice Location Address
First Line	:	1964 STATE ST
Second Line	:	SUITE 100
City	:	NEW ALBANY
State	:	IN
Zip	:	47150-4934
Country	:	US
Telephone Number	:	812-948-1641
Fax Number	:	812-941-0438

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/28/2005
Last Update Date	:	03/15/2011

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