Provider Demographics
NPI:1912910696
Name:HALL, JAMIE (MD)
Entity Type:Individual
Prefix:DR
First Name:JAMIE
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 1:5635 W FORT ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48209-3154
Mailing Address - Country:US
Mailing Address - Phone:313-849-3920
Mailing Address - Fax:313-849-0824
Practice Address - Street 1:7436 WOODWARD AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-3100
Practice Address - Country:US
Practice Address - Phone:313-556-9907
Practice Address - Fax:313-556-9711
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2014-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301063290207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
JH063290OtherCOMMERCIAL-COMMERCIAL NUMBER
MI339230710Medicaid
JH063290OtherCHAMPUS-CHAMPUS
080H262390OtherBLUE CROSS-BLUE CROSS
0H26239111Medicare ID - Type Unspecified
080H262390OtherBLUE CROSS-BLUE CROSS