Basic Information
| Provider Information | |||||||||
| NPI: | 1508974536 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HALLAM | ||||||||
| FirstName: | GARY | ||||||||
| MiddleName: | L. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 12020 | ||||||||
| Address2: | |||||||||
| City: | WESTMINSTER | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926852020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8885565617 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2801 'L' STREET | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95816 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9167333003 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2006 | ||||||||
| LastUpdateDate: | 10/08/2009 | ||||||||
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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 | 207P00000X | G24861 | CA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00G248610 | 05 | CA | MEDICAID |