Provider Demographics
NPI:1093836728
Name:HALL, MEDERIC MICAH (MD)
Entity Type:Individual
Prefix:
First Name:MEDERIC
Middle Name:MICAH
Last Name:HALL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2701 PRAIRIE MEADOW DR
Mailing Address - Street 2:
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52242-8001
Mailing Address - Country:US
Mailing Address - Phone:319-467-8059
Mailing Address - Fax:319-384-9305
Practice Address - Street 1:2701 PRAIRIE MEADOW DR
Practice Address - Street 2:
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52242-8001
Practice Address - Country:US
Practice Address - Phone:319-467-8059
Practice Address - Fax:319-384-9305
Is Sole Proprietor?:No
Enumeration Date:2007-04-02
Last Update Date:2014-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN49735208100000X
IA38299208100000X, 2081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN718425000Medicaid
MN250000761Medicare PIN