1083614416 NPI number — DR. ELI R HALLAL M.D.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083614416 NPI number — DR. ELI R HALLAL M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HALLAL
Provider First Name:
ELI
Provider Middle Name:
R
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1083614416
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/15/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1964 STATE ST
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
NEW ALBANY
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47150-4934
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
812-948-1641
Provider Business Mailing Address Fax Number:
812-941-0438

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1964 STATE ST
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
NEW ALBANY
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47150-4934
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-948-1641
Provider Business Practice Location Address Fax Number:
812-941-0438
Provider Enumeration Date:
07/28/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  01025361A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 100115500A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000042312 . This is a "ANTHEM" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 351359575 . This is a "COMMERCIAL" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: I001704 . This is a "TRICARE /CHAMPUS" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 35135957500 . This is a "OHIO BUREAU OF WORKERS' C" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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