Provider Demographics
NPI:1083656896
Name:HALL, PERRY L III (DO)
Entity Type:Individual
Prefix:
First Name:PERRY
Middle Name:L
Last Name:HALL
Suffix:III
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1836 LOCUST AVENUE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:FAIRMONT
Mailing Address - State:WV
Mailing Address - Zip Code:26554
Mailing Address - Country:US
Mailing Address - Phone:304-366-7767
Mailing Address - Fax:304-366-8837
Practice Address - Street 1:1836 LOCUST AVENUE
Practice Address - Street 2:SUITE 1
Practice Address - City:FAIRMONT
Practice Address - State:WV
Practice Address - Zip Code:26554
Practice Address - Country:US
Practice Address - Phone:304-366-7767
Practice Address - Fax:304-366-8837
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-13
Last Update Date:2020-03-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WVWV1611207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0055042000Medicaid
WV0833472Medicare ID - Type Unspecified
G11115Medicare UPIN