Provider Demographics
NPI:1225130842
Name:HALL, ROBERT GLENN (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:GLENN
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 1:115 N PEACHTREE AVE
Mailing Address - Street 2:
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38501-2546
Mailing Address - Country:US
Mailing Address - Phone:931-528-2836
Mailing Address - Fax:
Practice Address - Street 1:115 N PEACHTREE AVE
Practice Address - Street 2:
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501-2546
Practice Address - Country:US
Practice Address - Phone:931-528-2836
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD9327174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNB04116Medicare UPIN