Provider Demographics
NPI:1306883970
Name:HALL, LESLIE W (MD)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:W
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 743904
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3904
Mailing Address - Country:US
Mailing Address - Phone:803-296-7320
Mailing Address - Fax:803-296-7330
Practice Address - Street 1:1801 SUNSET DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6803
Practice Address - Country:US
Practice Address - Phone:803-434-4100
Practice Address - Fax:803-434-4155
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2021-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR2J99207R00000X
SC37695207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO394166OtherHEALTHLINK
MO202512513Medicaid
MO128011OtherBLUE SHIELD/BLUE CHOICE
MO400639OtherUNITED HEALTHCARE
SC732448Medicaid
MO110181199Medicare PIN
MO228011444Medicare PIN
MOD04494Medicare UPIN
MO202512513Medicaid