Provider Demographics
NPI:1104072230
Name:HALL, GLENN M JR (MD)
Entity type:Individual
Prefix:
First Name:GLENN
Middle Name:M
Last Name:HALL
Suffix:JR
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 1:3855 PLEASANT HILL RD STE 470
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-1417
Mailing Address - Country:US
Mailing Address - Phone:678-312-7280
Mailing Address - Fax:
Practice Address - Street 1:3855 PLEASANT HILL RD STE 470
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-1417
Practice Address - Country:US
Practice Address - Phone:678-312-7280
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-08
Last Update Date:2024-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.127088208600000X
GA98864208600000X
MI4301116458208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3124445Medicaid
OHH440410Medicare PIN