Provider Demographics
NPI:1104819978
Name:HALL, EDWARD C (MD)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:C
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:PO BOX 635283
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-5283
Mailing Address - Country:US
Mailing Address - Phone:859-301-2440
Mailing Address - Fax:859-301-2493
Practice Address - Street 1:1 MEDICAL VILLAGE DR
Practice Address - Street 2:
Practice Address - City:EDGEWOOD
Practice Address - State:KY
Practice Address - Zip Code:41017-3403
Practice Address - Country:US
Practice Address - Phone:859-301-2440
Practice Address - Fax:859-301-2493
Is Sole Proprietor?:No
Enumeration Date:2005-08-26
Last Update Date:2018-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY26580174400000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64265804Medicaid
KY160051936OtherRAIL ROAD MEDICARE
B96521Medicare UPIN
KY3400101Medicare PIN
KY3313201Medicare PIN
KY160051936OtherRAIL ROAD MEDICARE