Provider Demographics
NPI:1093759052
Name:HALL, RICHARD (PA)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:HALL
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8100
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97303-0900
Mailing Address - Country:US
Mailing Address - Phone:503-399-2424
Mailing Address - Fax:503-375-7429
Practice Address - Street 1:1155 MISSION ST SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-6228
Practice Address - Country:US
Practice Address - Phone:503-399-2424
Practice Address - Fax:503-375-7429
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2010-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA169367207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR196367Medicaid
OR1228590003Medicare NSC