Provider Demographics
NPI:1093893026
Name:HALL, MICHAEL JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JOHN
Last Name:HALL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:710 N NILES AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-1924
Mailing Address - Country:US
Mailing Address - Phone:574-647-1610
Mailing Address - Fax:
Practice Address - Street 1:100 NAVARRE PL STE 5500
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-1172
Practice Address - Country:US
Practice Address - Phone:574-647-5200
Practice Address - Fax:574-647-5210
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01063345A2085R0204X
WI1773 - 8502085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200855240Medicaid
IN000000773332OtherBCBS BMG VASCULAR INTERVENTIONAL RADIOLOGY
IN200855240Medicaid
IN000000773332OtherBCBS BMG VASCULAR INTERVENTIONAL RADIOLOGY
INP01146031OtherRR MEDICARE