Provider Demographics
NPI:1154387579
Name:HALL, HEATHER (MD)
Entity type:Individual
Prefix:DR
First Name:HEATHER
Middle Name:
Last Name:HALL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3255 BROWNLEE LN SW
Mailing Address - Street 2:
Mailing Address - City:LILBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30047-1907
Mailing Address - Country:US
Mailing Address - Phone:912-257-5719
Mailing Address - Fax:
Practice Address - Street 1:35 HOSPITAL WAY
Practice Address - Street 2:
Practice Address - City:BLAIRSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30512
Practice Address - Country:US
Practice Address - Phone:912-257-5719
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2016-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA055522207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA055522OtherLICENSE
GAP00336816OtherRAILROAD MEDICARE
GA512696750CMedicaid
GAI26754Medicare UPIN
GA08CBBTWMedicare PIN
GA512696750CMedicaid