Provider Demographics
NPI:1730317090
Name:HALL, GRAHAM CHARLES (MD)
Entity Type:Individual
Prefix:
First Name:GRAHAM
Middle Name:CHARLES
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 190930
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83719-0930
Mailing Address - Country:US
Mailing Address - Phone:208-367-5170
Mailing Address - Fax:208-367-5180
Practice Address - Street 1:1072 N LIBERTY ST STE 200
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8963
Practice Address - Country:US
Practice Address - Phone:208-302-4100
Practice Address - Fax:208-302-4135
Is Sole Proprietor?:No
Enumeration Date:2009-06-25
Last Update Date:2023-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01080885A207T00000X
KY47390208600000X
IDM-15928207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100142170Medicaid
IN300018084Medicaid
KYK136500Medicare PIN
KY7100142170Medicaid