Basic Information
| Provider Information | |||||||||
| NPI: | 1922072446 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HALL | ||||||||
| FirstName: | EDWARD | ||||||||
| MiddleName: | JASON | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 730 | ||||||||
| Address2: | 406 E ELM ST | ||||||||
| City: | CARSON CITY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48811 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9895843131 | ||||||||
| FaxNumber: | 9895846734 | ||||||||
| Practice Location | |||||||||
| Address1: | 1014 E WASHINGTON | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48838 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6167547145 | ||||||||
| FaxNumber: | 6167547110 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2006 | ||||||||
| LastUpdateDate: | 12/03/2009 | ||||||||
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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 | 207Q00000X | 5101014725 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 4592581 | 05 | MI | MEDICAID | 080195443 | 01 | MI | RAILROAD MEDICARE PTAN | OTHER |