Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2251G0304X | Physical Therapist - Geriatrics | 19852 | MD |
N | 2251G0304X | Physical Therapist - Geriatrics | 2305203397 | VA |
NPI | 1053450734 |
---|---|
Provider Name | Mr. Roger Hall |
First Address | Union Bridge, MD 21791-7707 |
Second Address | Towson, MD 21204-7673 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 06/02/2007 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
620633-01 | BC BS (01) | MD |