Basic Information
| Provider Information | |||||||||
| NPI: | 1124009741 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALLACE HALL | ||||||||
| FirstName: | MARIBETH | ||||||||
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| Credential: | CNM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 630 PLANTATION ST | ||||||||
| Address2: | |||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 016052038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5083683110 | ||||||||
| FaxNumber: | 5083683113 | ||||||||
| Practice Location | |||||||||
| Address1: | 123 SUMMER ST | ||||||||
| Address2: | SUITE 150 S | ||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 016081312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5083683110 | ||||||||
| FaxNumber: | 5083683113 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/10/2005 | ||||||||
| LastUpdateDate: | 03/04/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367A00000X | 146398 | MA | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
ID Information
| ID | Type | State | Issuer | Description | 04247226 | 01 | ONE HEALTH PLAN | OTHER | 420000565 | 01 | RAILROAD MEDICARE | OTHER | 0381110 | 01 | MEDICAID/WELFARE | OTHER | 9713805001 | 01 | CIGNA HEALTH PLAN | OTHER | CN0154 | 01 | BLUE CARE ELECT | OTHER | 2045900 | 01 | FIRST HEALTH | OTHER | 47094 | 01 | CHILDRENS MED SECURITY PL | OTHER | 042472266039 | 01 | TRICARE/CHAMPUS | OTHER | 61227 | 01 | FALLON COMMUNITY HLTH PL | OTHER | CN0154 | 01 | BLUE SHIELD INDEMNITY | OTHER | RN0029 | 01 | MEDICARE B | OTHER | 042472266 | 01 | HEALTHCARE VALUE MNGMENT | OTHER | 7956635 | 01 | AETNA/US HEALTHCARE | OTHER | CN0154 | 01 | BLUE SHIELD HMO BLUE | OTHER | 042472256 | 01 | PRIVATE HEALTHCARE SYSTEM | OTHER | 042472266 | 01 | THREE RIVERS | OTHER | 9713805001 | 01 | CIGNA PAL ID | OTHER | AA3471 | 01 | HARVARD PILGRIM HEALTHCAR | OTHER |