Basic Information
| Provider Information | |||||||||
| NPI: | 1174630933 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HALL | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | JOHN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 SOUTH AVE | ||||||||
| Address2: | BOX 58 | ||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146202733 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5853416202 | ||||||||
| FaxNumber: | 5853418305 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 SOUTH AVE | ||||||||
| Address2: | BOX 58 | ||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146202733 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5853416202 | ||||||||
| FaxNumber: | 5853418305 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0300X | 11847 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00488202 | 05 | NY | MEDICAID | 100630BJ | 01 | NY | PREFERRED CARE | OTHER |