Provider Demographics
NPI:1497702807
Name:HALL, CHARLES DANIEL (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:DANIEL
Last Name:HALL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:C
Other - Middle Name:DANIEL
Other - Last Name:HALL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 406
Mailing Address - Street 2:
Mailing Address - City:SUPPLY
Mailing Address - State:NC
Mailing Address - Zip Code:28462-0406
Mailing Address - Country:US
Mailing Address - Phone:910-754-6220
Mailing Address - Fax:
Practice Address - Street 1:610B OCEAN HWY W
Practice Address - Street 2:
Practice Address - City:SUPPLY
Practice Address - State:NC
Practice Address - Zip Code:28462-4048
Practice Address - Country:US
Practice Address - Phone:910-754-6220
Practice Address - Fax:910-754-6216
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC94012052084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC05-28877OtherUNITED HEALTHCARE
NC38465OtherBCBSNC
NC8938465Medicaid
NC05-28877OtherUNITED HEALTHCARE
NC2207278AMedicare ID - Type UnspecifiedCIGNA MEDICARE
NC1088430001Medicare NSC