Basic Information
| Provider Information | |||||||||
| NPI: | 1346468105 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HALL | ||||||||
| FirstName: | HEATHER | ||||||||
| MiddleName: | ANNE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2350 N ROCKTON AVE | ||||||||
| Address2: | |||||||||
| City: | ROCKFORD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 611033600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8159712248 | ||||||||
| FaxNumber: | 8159719097 | ||||||||
| Practice Location | |||||||||
| Address1: | 2350 N ROCKTON AVE | ||||||||
| Address2: | |||||||||
| City: | ROCKFORD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 611033600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8159712248 | ||||||||
| FaxNumber: | 8159719097 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2007 | ||||||||
| LastUpdateDate: | 04/29/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0129X | 036.123091 | IL | Y | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
ID Information
| ID | Type | State | Issuer | Description | 036123091 | 01 | IL | STATE LICENSE | OTHER |