Basic Information
Provider Information | |||||||||
NPI: | 1114934221 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BERDEAUX | ||||||||
FirstName: | DONALD | ||||||||
MiddleName: | HALL | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 6010 | ||||||||
Address2: |   | ||||||||
City: | GREAT FALLS | ||||||||
State: | MT | ||||||||
PostalCode: | 594066010 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4067318888 | ||||||||
FaxNumber: | 4067318876 | ||||||||
Practice Location | |||||||||
Address1: | 1117 29TH ST S | ||||||||
Address2: |   | ||||||||
City: | GREAT FALLS | ||||||||
State: | MT | ||||||||
PostalCode: | 594055306 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4067318200 | ||||||||
FaxNumber: | 4067318178 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/02/2006 | ||||||||
LastUpdateDate: | 03/11/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | 7270 | MT | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
ID | Type | State | Issuer | Description | 0000094908 | 01 | MT | BCBS | OTHER | 1114934221 | 05 | MT |   | MEDICAID | 830006549 | 01 | MT | RAILROAD MEDICARE | OTHER |