Provider Demographics
NPI:1699718791
Name:HALL, ROBERT WINSTON (MD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:WINSTON
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 6489
Mailing Address - Street 2:404 BROADWAY BLVD
Mailing Address - City:KETCHUM
Mailing Address - State:ID
Mailing Address - Zip Code:83340-6489
Mailing Address - Country:US
Mailing Address - Phone:208-726-8024
Mailing Address - Fax:
Practice Address - Street 1:180 WEST FIRST ST.
Practice Address - Street 2:SUITE 214
Practice Address - City:KETCHUM
Practice Address - State:ID
Practice Address - Zip Code:83340
Practice Address - Country:US
Practice Address - Phone:208-726-5996
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM6584207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDC97102Medicare UPIN
ID1130739Medicare ID - Type Unspecified