Provider Demographics
NPI:1144248493
Name:HALL, PHILLIP K (MD)
Entity type:Individual
Prefix:
First Name:PHILLIP
Middle Name:K
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 1:10727 FALLS CREEK LN
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45458-6063
Mailing Address - Country:US
Mailing Address - Phone:937-885-4310
Mailing Address - Fax:
Practice Address - Street 1:5300 FAR HILLS AVE.
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45429-2347
Practice Address - Country:US
Practice Address - Phone:937-433-7536
Practice Address - Fax:937-433-9612
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2016-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35070320H207ND0101X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0649150OtherAETNA
OH3109647743A18OtherANTHEM BLUE SHIELD
OHOC02792OtherNATIONWIDE
OH0300288OtherUNITED HEALTH CARE
OH0649150OtherAETNA
OHF54600Medicare UPIN