MEDICARE: DR. SALLY ANN HALLGREN D.O.

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	207LP2900X	Pain Medicine (Anesthesiology) Physician	E9484	TX
2	208VP0000X	Pain Medicine Physician	E9484	TX

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

General Provider Information

NPI Number	:	1114915402
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SALLY ANN HALLGREN D.O.

Provider Business Mailing Address
First Line	:	311 UNIVERSITY DR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76107-1924
Country	:	US
Telephone Number	:	817-877-4787
Fax Number	:	817-877-1654

Provider Business Practice Location Address
First Line	:	311 UNIVERSITY DR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76107-1924
Country	:	US
Telephone Number	:	817-877-4787
Fax Number	:	817-877-1654

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

Provider Enumeration Date	:	10/11/2005
Last Update Date	:	02/22/2012

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Directions to “ DR. SALLY ANN HALLGREN D.O.” Practice Location

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