Basic Information
| Provider Information | |||||||||
| NPI: | 1578527883 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HALL | ||||||||
| FirstName: | BRENT | ||||||||
| MiddleName: | DWAYNE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1867 | ||||||||
| Address2: | |||||||||
| City: | BLUEFIELD | ||||||||
| State: | WV | ||||||||
| PostalCode: | 247015867 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043234320 | ||||||||
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| Practice Location | |||||||||
| Address1: | 336 DEERFIELD RD | ||||||||
| Address2: | |||||||||
| City: | BOONE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286075008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8282624100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2006 | ||||||||
| LastUpdateDate: | 04/03/2018 | ||||||||
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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 | 207ZP0102X | 34026 | NC | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 8938287 | 05 | NC | MEDICAID |