Provider Demographics
NPI:1689665275
Name:HALL, NINA KEITH (MD)
Entity Type:Individual
Prefix:DR
First Name:NINA
Middle Name:KEITH
Last Name:HALL
Suffix:
Gender:F
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 33369
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28233-3369
Mailing Address - Country:US
Mailing Address - Phone:704-364-8100
Mailing Address - Fax:704-365-2073
Practice Address - Street 1:2001 VAIL AVE STE 320
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28207-1222
Practice Address - Country:US
Practice Address - Phone:704-364-8100
Practice Address - Fax:337-783-4625
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2022-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2017-01535208600000X
LA200486207R00000X
LAMD200486208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1590321Medicaid
LA1590321Medicaid
LA4J915Medicare PIN
LAP00392359Medicare PIN