Provider Demographics
NPI:1841405610
Name:JOHN T HALL M.D.
Entity Type:Organization
Organization Name:JOHN T HALL M.D.
Other - Org Name:BENTON RURAL HEALTH CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:CATHY
Authorized Official - Middle Name:D
Authorized Official - Last Name:LISENBY
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:618-435-2505
Mailing Address - Street 1:401 E PARK ST
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:IL
Mailing Address - Zip Code:62812-1920
Mailing Address - Country:US
Mailing Address - Phone:618-435-2505
Mailing Address - Fax:618-438-6015
Practice Address - Street 1:401 E PARK ST
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:IL
Practice Address - Zip Code:62812-1920
Practice Address - Country:US
Practice Address - Phone:618-435-2505
Practice Address - Fax:618-438-6015
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-14
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========0002Medicaid
ILC41502Medicare UPIN
IL=========0002Medicaid