Provider Demographics
NPI:1124009741
Name:WALLACE HALL, MARIBETH (CNM)
Entity Type:Individual
Prefix:
First Name:MARIBETH
Middle Name:
Last Name:WALLACE HALL
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 PLANTATION ST
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01605-2038
Mailing Address - Country:US
Mailing Address - Phone:508-368-3110
Mailing Address - Fax:508-368-3113
Practice Address - Street 1:123 SUMMER ST
Practice Address - Street 2:SUITE 150 S
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01608-1312
Practice Address - Country:US
Practice Address - Phone:508-368-3110
Practice Address - Fax:508-368-3113
Is Sole Proprietor?:No
Enumeration Date:2005-11-10
Last Update Date:2009-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA146398367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
04247226OtherONE HEALTH PLAN
420000565OtherRAILROAD MEDICARE
0381110OtherMEDICAID/WELFARE
9713805001OtherCIGNA HEALTH PLAN
CN0154OtherBLUE CARE ELECT
2045900OtherFIRST HEALTH
47094OtherCHILDRENS MED SECURITY PL
042472266039OtherTRICARE/CHAMPUS
61227OtherFALLON COMMUNITY HLTH PL
CN0154OtherBLUE SHIELD INDEMNITY
RN0029OtherMEDICARE B
042472266OtherHEALTHCARE VALUE MNGMENT
7956635OtherAETNA/US HEALTHCARE
CN0154OtherBLUE SHIELD HMO BLUE
042472256OtherPRIVATE HEALTHCARE SYSTEM
042472266OtherTHREE RIVERS
9713805001OtherCIGNA PAL ID
AA3471OtherHARVARD PILGRIM HEALTHCAR
RN0029Medicare ID - Type Unspecified
CN0154OtherBLUE SHIELD HMO BLUE