Provider Demographics
NPI:1710182407
Name:HALL, ANDREW M
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:M
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 1:1210 S OLD DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:JUPITER
Mailing Address - State:FL
Mailing Address - Zip Code:33458-7205
Mailing Address - Country:US
Mailing Address - Phone:561-743-5007
Mailing Address - Fax:
Practice Address - Street 1:1210 S OLD DIXIE HWY
Practice Address - Street 2:
Practice Address - City:JUPITER
Practice Address - State:FL
Practice Address - Zip Code:33458-7205
Practice Address - Country:US
Practice Address - Phone:561-743-5007
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-20
Last Update Date:2024-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1118662085R0204X, 2085R0204X
IL0361266962085R0202X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program