Provider Demographics
NPI:1164546164
Name:HALL, I SCOTT (MD)
Entity Type:Individual
Prefix:DR
First Name:I
Middle Name:SCOTT
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 1:18160 COTTONWOOD RD PMB 459
Mailing Address - Street 2:
Mailing Address - City:SUNRIVER
Mailing Address - State:OR
Mailing Address - Zip Code:97707-9317
Mailing Address - Country:US
Mailing Address - Phone:541-598-2075
Mailing Address - Fax:
Practice Address - Street 1:18160 COTTONWOOD RD PMB 459
Practice Address - Street 2:
Practice Address - City:SUNRIVER
Practice Address - State:OR
Practice Address - Zip Code:97707-9317
Practice Address - Country:US
Practice Address - Phone:541-598-2075
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA0015149207R00000X
ORMD22944207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1498906Medicaid
WA102042Medicare ID - Type Unspecified
WAA04633Medicare UPIN