Provider Demographics
NPI:1720105364
Name:HALL, ROY EVERETTE (MD)
Entity Type:Individual
Prefix:
First Name:ROY
Middle Name:EVERETTE
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 1:1368 SOUTHLAKE PROFESSIONAL PLAZA DR
Mailing Address - Street 2:
Mailing Address - City:MORROW
Mailing Address - State:GA
Mailing Address - Zip Code:30260
Mailing Address - Country:US
Mailing Address - Phone:678-422-8824
Mailing Address - Fax:678-422-7291
Practice Address - Street 1:1368 SOUTHLAKE PROFESSIONAL PLAZA DR
Practice Address - Street 2:
Practice Address - City:MORROW
Practice Address - State:GA
Practice Address - Zip Code:30260
Practice Address - Country:US
Practice Address - Phone:678-422-8824
Practice Address - Fax:678-422-7291
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2018-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0552342083P0500X, 207Q00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No2083P0500XAllopathic & Osteopathic PhysiciansPreventive MedicinePreventive Medicine/Occupational Environmental Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA511G700201Medicare PIN
GA202I010539Medicare UPIN