Provider Demographics
NPI:1336144047
Name:HALL, LAURA F (MD)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:F
Last Name:HALL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:M
Other - Last Name:FIDDELKE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 191
Mailing Address - Street 2:PROVIDER ENROLLMENT DEPT
Mailing Address - City:ROCKLAND
Mailing Address - State:DE
Mailing Address - Zip Code:19732-0191
Mailing Address - Country:US
Mailing Address - Phone:302-651-6212
Mailing Address - Fax:302-651-4945
Practice Address - Street 1:200 CLEAVER FARM ROAD
Practice Address - Street 2:SUITE 201
Practice Address - City:MIDDLETOWN
Practice Address - State:DE
Practice Address - Zip Code:19709-1630
Practice Address - Country:US
Practice Address - Phone:302-378-5100
Practice Address - Fax:302-378-5106
Is Sole Proprietor?:No
Enumeration Date:2005-06-17
Last Update Date:2011-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD019816E208000000X
DEC10008675208000000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA122124OtherHIGHMARK
PA163798OtherTHREE RIVERS MEDPLUS
PA0007781280011Medicaid
PA4544416OtherAETNA MANAGED CHOICE
PA468922OtherAETNA HMO
PA200373OtherUPMC FOR YOU
PAP000696OtherGATEWAY
PA4544416OtherAETNA MANAGED CHOICE