Provider Demographics
NPI:1104806413
Name:HALE, JOHN W JR (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:W
Last Name:HALE
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 1:965 RIDGE LAKE BLVD STE 103
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-9446
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:901-227-8591
Practice Address - Street 1:1412 E REELFOOT AVE
Practice Address - Street 2:
Practice Address - City:UNION CITY
Practice Address - State:TN
Practice Address - Zip Code:38261-5813
Practice Address - Country:US
Practice Address - Phone:731-885-5131
Practice Address - Fax:731-885-5335
Is Sole Proprietor?:No
Enumeration Date:2006-01-20
Last Update Date:2020-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN19519207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3043584Medicaid
TN080091651OtherRAILROAD MEDICARE
TN3043584Medicaid
D93186Medicare UPIN