Provider Demographics
NPI:1265506448
Name:HALL, MARY JEAN (MEDICAL DOCTOR)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:JEAN
Last Name:HALL
Suffix:
Gender:F
Credentials:MEDICAL DOCTOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1615
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26507-1615
Mailing Address - Country:US
Mailing Address - Phone:304-285-3679
Mailing Address - Fax:304-285-3694
Practice Address - Street 1:1000 MON HEALTH MEDICAL PARK DR
Practice Address - Street 2:SUITE 1100
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26505-1104
Practice Address - Country:US
Practice Address - Phone:304-599-1448
Practice Address - Fax:304-598-7219
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2016-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV20379207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
001712123OtherBCBS
WV2004673000Medicaid
WVP01617603OtherRAILROAD
WVP01617603OtherRAILROAD
WVWV6328C185Medicare PIN