Provider Demographics
NPI:1013055920
Name:HALL, LARRY (MD)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:
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 K
Mailing Address - Street 2:
Mailing Address - City:MAYFIELD
Mailing Address - State:KY
Mailing Address - Zip Code:42066-0016
Mailing Address - Country:US
Mailing Address - Phone:270-247-0667
Mailing Address - Fax:
Practice Address - Street 1:2000 HOLIDAY LN
Practice Address - Street 2:
Practice Address - City:FULTON
Practice Address - State:KY
Practice Address - Zip Code:42041-8468
Practice Address - Country:US
Practice Address - Phone:270-472-8372
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-02
Last Update Date:2015-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY13780146D00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146D00000XEmergency Medical Service ProvidersPersonal Emergency Response Attendant
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000337173OtherBCBS
P00132977OtherRR MCR
KY64137805Medicaid
KY0933206Medicare PIN
P00132977OtherRR MCR