Provider Demographics
NPI:1780688366
Name:HALL, MICHAEL M (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:M
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 1:100 HOSPITAL AVE
Mailing Address - Street 2:
Mailing Address - City:DU BOIS
Mailing Address - State:PA
Mailing Address - Zip Code:15801-1440
Mailing Address - Country:US
Mailing Address - Phone:814-375-6560
Mailing Address - Fax:814-372-2848
Practice Address - Street 1:145 HOSPITAL AVE
Practice Address - Street 2:STE 104
Practice Address - City:DU BOIS
Practice Address - State:PA
Practice Address - Zip Code:15801-1463
Practice Address - Country:US
Practice Address - Phone:814-375-8055
Practice Address - Fax:814-375-8056
Is Sole Proprietor?:No
Enumeration Date:2005-06-10
Last Update Date:2019-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD036517E207Q00000X, 207QA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001132739Medicaid
PA591707Q09OtherMC PTAN
PA852695FFUOtherMC PTAN
PA506955Medicare PIN