Provider Demographics
NPI:1154308765
Name:HALL, JEFFREY WAYNE (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:WAYNE
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:PO BOX 743904
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3904
Mailing Address - Country:US
Mailing Address - Phone:803-296-7320
Mailing Address - Fax:803-296-7330
Practice Address - Street 1:3209 COLONIAL DRIVE
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203
Practice Address - Country:US
Practice Address - Phone:803-434-6113
Practice Address - Fax:803-434-7231
Is Sole Proprietor?:No
Enumeration Date:2005-12-23
Last Update Date:2018-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC24397207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC6680499OtherCIGNA
SCP00031198OtherRAILROAD MEDICARE
SCT84192Medicaid
SCH868813093Medicare PIN
SCH868812353Medicare PIN
SCT84192Medicaid