Provider Demographics
NPI:1740833219
Name:HALL, VIRGINIA ANN
Entity type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:ANN
Last Name:HALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18509 SCHOOL ST APT 2B
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:IL
Mailing Address - Zip Code:60438-2946
Mailing Address - Country:US
Mailing Address - Phone:773-844-1942
Mailing Address - Fax:
Practice Address - Street 1:18509 SCHOOL ST APT 2B
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:IL
Practice Address - Zip Code:60438-2946
Practice Address - Country:US
Practice Address - Phone:773-844-1942
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-23
Last Update Date:2019-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAH40086159748172A00000X
343900000X, 347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle
No172A00000XOther Service ProvidersDriver
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL20190722011617Medicaid
IL2019072211617Medicaid