Provider Demographics
NPI:1922012194
Name:HALL, TIMOTHY S (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:S
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 1:1025 MICHIGAN AVE
Mailing Address - Street 2:SUITE 115
Mailing Address - City:LOGANSPORT
Mailing Address - State:IN
Mailing Address - Zip Code:46947-1665
Mailing Address - Country:US
Mailing Address - Phone:574-722-3566
Mailing Address - Fax:574-753-6118
Practice Address - Street 1:1025 MICHIGAN AVE
Practice Address - Street 2:SUITE 115
Practice Address - City:LOGANSPORT
Practice Address - State:IN
Practice Address - Zip Code:46947-1665
Practice Address - Country:US
Practice Address - Phone:574-722-3566
Practice Address - Fax:574-753-6118
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2013-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9600933207V00000X
IN01072086A207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000804357OtherANTHEM
IN201131010Medicaid
NC8938668Medicaid
CH3883OtherRAIL ROAD MEDICARE
INP01168138OtherRAIL ROAD
NC2227647DMedicare ID - Type Unspecified
IN940670008Medicare PIN
INP01168138OtherRAIL ROAD