Provider Demographics
NPI:1558337857
Name:HALL, JACK J (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:J
Last Name:HALL
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 1:619 E MASON ST STE 4P57
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62701-1034
Mailing Address - Country:US
Mailing Address - Phone:217-788-0706
Mailing Address - Fax:217-525-2535
Practice Address - Street 1:619 E MASON ST STE 4P57
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62701
Practice Address - Country:US
Practice Address - Phone:217-788-0706
Practice Address - Fax:217-525-2535
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01038562A207RC0000X, 207RI0011X
MT129026207RI0011X
IL036136720207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200063500Medicaid
ILP01427268OtherRAILROAD
IN200063500Medicaid
ILP01427268OtherRAILROAD
IN898190B8Medicare ID - Type Unspecified
ING16121Medicare UPIN
IN200063500Medicaid