Provider Demographics
NPI:1548254063
Name:HALL, COURTLAND (MD)
Entity type:Individual
Prefix:
First Name:COURTLAND
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 1:3203 TAHOE PEAK PL
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57702-5238
Mailing Address - Country:US
Mailing Address - Phone:605-341-3024
Mailing Address - Fax:
Practice Address - Street 1:216 ANAMARIA DR
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-7366
Practice Address - Country:US
Practice Address - Phone:605-721-0337
Practice Address - Fax:605-721-0043
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD2806207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5700762Medicaid
D01170Medicare UPIN
SD6655Medicare ID - Type Unspecified