Basic Information
Provider Information | |||||||||
NPI: | 1669683462 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HALL | ||||||||
FirstName: | SHAWN | ||||||||
MiddleName: | M | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | DO | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 900 PEELER ST | ||||||||
Address2: |   | ||||||||
City: | KALAMAZOO | ||||||||
State: | MI | ||||||||
PostalCode: | 490082300 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2693458618 | ||||||||
FaxNumber: | 2693451508 | ||||||||
Practice Location | |||||||||
Address1: | 900 PEELER ST | ||||||||
Address2: |   | ||||||||
City: | KALAMAZOO | ||||||||
State: | MI | ||||||||
PostalCode: | 490082300 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2693458618 | ||||||||
FaxNumber: | 2693451508 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/24/2007 | ||||||||
LastUpdateDate: | 08/12/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 34.008340 | OH | N |   | Allopathic & Osteopathic Physicians | Anesthesiology |   | 207L00000X | 5101015562 | MI | Y |   | Allopathic & Osteopathic Physicians | Anesthesiology |   |
ID Information
ID | Type | State | Issuer | Description | 2771022 | 05 | OH |   | MEDICAID | 000000225048 | 01 | OH | UNISON | OTHER | 000000533057 | 01 | OH | ANTHEM | OTHER | 0583328 | 01 | OH | BCMH | OTHER | 751149 | 01 | OH | BUCKEYE MEDICAID | OTHER | 417902 | 01 | OH | WELLCARE MEDICAID | OTHER | 9671066 | 01 | OH | AETNA | OTHER |