Provider Demographics
NPI:1063475358
Name:THALL, EDMOND HARTLEY (MD)
Entity type:Individual
Prefix:DR
First Name:EDMOND
Middle Name:HARTLEY
Last Name:THALL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:223 GRAPPA FARMS DR
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44143-3720
Mailing Address - Country:US
Mailing Address - Phone:231-220-5369
Mailing Address - Fax:
Practice Address - Street 1:223 GRAPPA FARMS DR
Practice Address - Street 2:
Practice Address - City:HIGHLAND HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44143-3720
Practice Address - Country:US
Practice Address - Phone:231-220-5369
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-09
Last Update Date:2024-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD033759E207W00000X
CO42566207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO64432017Medicaid
TX127627104Medicaid
CO64432017Medicaid
C30597Medicare UPIN
CO532978Medicare ID - Type UnspecifiedCO (NORIDIAN) MEDICARE #
TX82632JMedicare ID - Type UnspecifiedTX MEDICARE ALSO BC/BS