Provider Demographics
NPI:1104803493
Name:HALL, BRUCE A (MD)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:A
Last Name:HALL
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 1:300 W WHITE MOUNTAIN BLVD
Mailing Address - Street 2:STE D
Mailing Address - City:LAKESIDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85929-7014
Mailing Address - Country:US
Mailing Address - Phone:928-368-4547
Mailing Address - Fax:928-368-4527
Practice Address - Street 1:2200 E SHOW LOW LAKE RD
Practice Address - Street 2:
Practice Address - City:SHOW LOW
Practice Address - State:AZ
Practice Address - Zip Code:85901-7881
Practice Address - Country:US
Practice Address - Phone:928-537-4375
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-28
Last Update Date:2017-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ25444207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ405820Medicaid
AZ405820Medicaid
AZ21152Medicare PIN