Provider Demographics
NPI:1376142026
Name:HALL, TIMOTHY MICHAEL
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:MICHAEL
Last Name:HALL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15347 WHEELER RD
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:OH
Mailing Address - Zip Code:44050-9707
Mailing Address - Country:US
Mailing Address - Phone:440-365-6859
Mailing Address - Fax:
Practice Address - Street 1:15347 WHEELER RD
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:OH
Practice Address - Zip Code:44050-9707
Practice Address - Country:US
Practice Address - Phone:440-365-6859
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-23
Last Update Date:2020-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH4702307Medicaid