Provider Demographics
NPI:1578527883
Name:HALL, BRENT DWAYNE (MD)
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:DWAYNE
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:PO BOX 1867
Mailing Address - Street 2:
Mailing Address - City:BLUEFIELD
Mailing Address - State:WV
Mailing Address - Zip Code:24701-5867
Mailing Address - Country:US
Mailing Address - Phone:304-323-4320
Mailing Address - Fax:
Practice Address - Street 1:336 DEERFIELD RD
Practice Address - Street 2:
Practice Address - City:BOONE
Practice Address - State:NC
Practice Address - Zip Code:28607-5008
Practice Address - Country:US
Practice Address - Phone:828-262-4100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2018-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC34026207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8938287Medicaid
NC2189468BMedicare PIN
NC8938287Medicaid
NC220027497Medicare PIN