Provider Demographics
NPI:1558473645
Name:JOHN HALL, M.D., P.C.
Entity Type:Organization
Organization Name:JOHN HALL, M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:T
Authorized Official - Last Name:HALL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-244-7788
Mailing Address - Street 1:3505 BROADWAY ST
Mailing Address - Street 2:STE A
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-2202
Mailing Address - Country:US
Mailing Address - Phone:618-244-7788
Mailing Address - Fax:618-244-9330
Practice Address - Street 1:3505 BROADWAY ST
Practice Address - Street 2:STE A
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-2202
Practice Address - Country:US
Practice Address - Phone:618-244-7788
Practice Address - Fax:618-244-9330
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36060706207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILC41502Medicare UPIN
IL675321Medicare ID - Type UnspecifiedPROVIDER NUMBER