Provider Demographics
NPI:1811991342
Name:HALL, MYRA JANE (MD)
Entity type:Individual
Prefix:
First Name:MYRA
Middle Name:JANE
Last Name:HALL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 MAGNOLIA SQUARE COURT
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN
Mailing Address - State:NC
Mailing Address - Zip Code:28315-2226
Mailing Address - Country:US
Mailing Address - Phone:910-944-0779
Mailing Address - Fax:910-944-2298
Practice Address - Street 1:210 MAGNOLIA SQUARE COURT
Practice Address - Street 2:
Practice Address - City:ABERDEEN
Practice Address - State:NC
Practice Address - Zip Code:28315-2226
Practice Address - Country:US
Practice Address - Phone:910-944-0779
Practice Address - Fax:910-944-2298
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-13
Last Update Date:2011-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC36463170100000X
NC22874207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No170100000XOther Service ProvidersMedical Genetics, Ph.D. Medical Genetics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8911477Medicaid
NC8911477Medicaid
G18022Medicare UPIN
NCG18022Medicare UPIN