Provider Demographics
NPI:1205860673
Name:HALL, JOHNNIE CAMERON (MD)
Entity Type:Individual
Prefix:
First Name:JOHNNIE
Middle Name:CAMERON
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 1:7550 WOLF RIVER BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38138-1745
Mailing Address - Country:US
Mailing Address - Phone:901-542-6801
Mailing Address - Fax:901-542-6871
Practice Address - Street 1:7550 WOLF RIVER BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138-1745
Practice Address - Country:US
Practice Address - Phone:901-542-6801
Practice Address - Fax:901-542-6871
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2008-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000016469207ZP0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR115043001Medicaid
MO202580007Medicaid
TN3042151Medicaid
TN3031633OtherBLUE CROSS BLUE SHIELD
AR96810OtherBLUE CROSS
TN000000004129Medicaid
MS0019203Medicaid
TN3031633Medicaid
TN3042151Medicaid
MS0019203Medicaid
AR115043001Medicaid