Provider Demographics
NPI:1265524037
Name:HALL, SOMMER C (PT)
Entity type:Individual
Prefix:
First Name:SOMMER
Middle Name:C
Last Name:HALL
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:SOMMER
Other - Middle Name:C
Other - Last Name:GUALDONI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6500 BOWDEN RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-8070
Mailing Address - Country:US
Mailing Address - Phone:904-634-0640
Mailing Address - Fax:904-634-0203
Practice Address - Street 1:10475 CENTURION PKWY N
Practice Address - Street 2:SUITE 220
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-5003
Practice Address - Country:US
Practice Address - Phone:904-634-0640
Practice Address - Fax:904-634-0203
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2015-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070013911225100000X
FLPT272132251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00931617OtherMEDICARE RAILROAD
ILR02458Medicare PIN
IL202845134Medicare PIN
ILP00931617OtherMEDICARE RAILROAD
IL216859097Medicare PIN
ILP00336821Medicare PIN
ILK09981Medicare PIN