Basic Information
| Provider Information | |||||||||
| NPI: | 1306883970 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HALL | ||||||||
| FirstName: | LESLIE | ||||||||
| MiddleName: | W | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 743904 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303743904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8032967320 | ||||||||
| FaxNumber: | 8032967330 | ||||||||
| Practice Location | |||||||||
| Address1: | 1801 SUNSET DR | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292036803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8034344100 | ||||||||
| FaxNumber: | 8034344155 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2006 | ||||||||
| LastUpdateDate: | 04/23/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | R2J99 | MO | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 37695 | SC | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 394166 | 01 | MO | HEALTHLINK | OTHER | 202512513 | 05 | MO | MEDICAID | 128011 | 01 | MO | BLUE SHIELD/BLUE CHOICE | OTHER | 400639 | 01 | MO | UNITED HEALTHCARE | OTHER | 732448 | 05 | SC | MEDICAID |