Basic Information
| Provider Information | |||||||||
| NPI: | 1144569484 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HALL | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | DARYL | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1500 E SHOTWELL ST | ||||||||
| Address2: | |||||||||
| City: | BAINBRIDGE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 398194256 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2292463500 | ||||||||
| FaxNumber: | 2292433342 | ||||||||
| Practice Location | |||||||||
| Address1: | 1500 E SHOTWELL ST | ||||||||
| Address2: | |||||||||
| City: | BAINBRIDGE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 398194256 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2292463500 | ||||||||
| FaxNumber: | 2292433342 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/06/2013 | ||||||||
| LastUpdateDate: | 02/06/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT010747 | GA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.