Provider Demographics
NPI:1992864417
Name:HALL, LISA MARIE (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:HALL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:52915 MOUND ROAD
Mailing Address - Street 2:
Mailing Address - City:SHELBY TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48316-3266
Mailing Address - Country:US
Mailing Address - Phone:586-992-2400
Mailing Address - Fax:586-992-8206
Practice Address - Street 1:52915 MOUND ROAD
Practice Address - Street 2:
Practice Address - City:SHELBY TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48316-3266
Practice Address - Country:US
Practice Address - Phone:586-992-2400
Practice Address - Fax:586-992-8206
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-08
Last Update Date:2012-12-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301074129207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIH58345Medicare UPIN