Provider Demographics
NPI:1528061058
Name:HALL, MICHAEL D (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:D
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 1:681 BOCAGE LN
Mailing Address - Street 2:
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70471-1605
Mailing Address - Country:US
Mailing Address - Phone:985-792-5537
Mailing Address - Fax:
Practice Address - Street 1:95 JUDGE TANNER BLVD
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433-7500
Practice Address - Country:US
Practice Address - Phone:985-867-4050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-05-30
Last Update Date:2012-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA0250112085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1420981Medicaid
LA1420981Medicaid
LA4F6497808Medicare PIN
LAH99143Medicare UPIN
LAP00314624Medicare PIN