Basic Information
Provider Information
NPI: 1386625572
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: HALL
FirstName: JOHN
MiddleName: W.
NamePrefix: DR.
NameSuffix:  
Credential: MD
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 190 RIVERSIDE ST
Address2: SUITE 6B
City: PORTLAND
State: ME
PostalCode: 041031073
CountryCode: US
TelephoneNumber: 2076612000
FaxNumber:  
Practice Location
Address1: 49 SPRING ST
Address2: 1ST FLOOR
City: SCARBOROUGH
State: ME
PostalCode: 040748926
CountryCode: US
TelephoneNumber: 2078850011
FaxNumber: 2078855851
Other Information
ProviderEnumerationDate: 11/07/2005
LastUpdateDate: 04/26/2017
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
2081P2900X016009MEY Allopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine

ID Information
IDTypeStateIssuerDescription
3020963905NH MEDICAID
18787009905ME MEDICAID


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