Provider Demographics
NPI:1710970025
Name:HALL, GREGORY BRUNO (MD FACS)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:BRUNO
Last Name:HALL
Suffix:
Gender:M
Credentials:MD FACS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 FAIRVIEW RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117-9504
Mailing Address - Country:US
Mailing Address - Phone:704-664-6677
Mailing Address - Fax:704-663-1009
Practice Address - Street 1:150 FAIRVIEW RD
Practice Address - Street 2:SUITE 300
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117-9504
Practice Address - Country:US
Practice Address - Phone:704-664-6677
Practice Address - Fax:704-663-1009
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-23
Last Update Date:2010-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9600335174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8938320Medicaid
NCG46381Medicare UPIN
NC2222908BMedicare PIN