Provider Demographics
NPI:1619387073
Name:HALL, ERIC R
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:R
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 1:3901 STEWART AVE
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54401-3948
Mailing Address - Country:US
Mailing Address - Phone:715-907-0900
Mailing Address - Fax:715-803-6977
Practice Address - Street 1:4002 SCHOFIELD AVE STE 2
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:WI
Practice Address - Zip Code:54476-3809
Practice Address - Country:US
Practice Address - Phone:715-870-2422
Practice Address - Fax:715-870-2428
Is Sole Proprietor?:No
Enumeration Date:2014-05-06
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12317-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100040179Medicaid