Provider Demographics
NPI:1871706374
Name:JOHN HALL MD RURAL HEALTH SERVICES
Entity type:Organization
Organization Name:JOHN HALL MD RURAL HEALTH SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:CATHY
Authorized Official - Middle Name:D
Authorized Official - Last Name:LISENBY
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:618-244-7788
Mailing Address - Street 1:3505 BROADWAY ST STE A
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-2202
Mailing Address - Country:US
Mailing Address - Phone:618-244-7788
Mailing Address - Fax:618-244-9330
Practice Address - Street 1:3505 BROADWAY ST STE A
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-2202
Practice Address - Country:US
Practice Address - Phone:618-244-7788
Practice Address - Fax:618-244-9330
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-08
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========0003Medicaid
IL148943Medicare Oscar/Certification
ILC41502Medicare UPIN