Provider Demographics
NPI:1558833020
Name:HALL, TONY
Entity Type:Individual
Prefix:
First Name:TONY
Middle Name:
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 1:15940 SAINT LOUIS AVE
Mailing Address - Street 2:
Mailing Address - City:MARKHAM
Mailing Address - State:IL
Mailing Address - Zip Code:60428-4019
Mailing Address - Country:US
Mailing Address - Phone:708-745-0846
Mailing Address - Fax:
Practice Address - Street 1:15940 SAINT LOUIS AVE
Practice Address - Street 2:
Practice Address - City:MARKHAM
Practice Address - State:IL
Practice Address - Zip Code:60428-4019
Practice Address - Country:US
Practice Address - Phone:708-745-0846
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-21
Last Update Date:2018-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILH40081288177172A00000X
172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver