Provider Demographics
NPI:1275989725
Name:HALLENBECK, MICHAEL REVERE (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:REVERE
Last Name:HALLENBECK
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 1:2505 US HIGHWAY 431
Mailing Address - Street 2:
Mailing Address - City:BOAZ
Mailing Address - State:AL
Mailing Address - Zip Code:35957-5908
Mailing Address - Country:US
Mailing Address - Phone:256-593-8310
Mailing Address - Fax:
Practice Address - Street 1:2505 US HIGHWAY 431
Practice Address - Street 2:
Practice Address - City:BOAZ
Practice Address - State:AL
Practice Address - Zip Code:35957-5908
Practice Address - Country:US
Practice Address - Phone:256-593-8310
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-13
Last Update Date:2023-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL44718208000000X
TN61516207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics