Provider Demographics
NPI:1770718587
Name:HALL, QUINCY G (IDMT)
Entity type:Individual
Prefix:
First Name:QUINCY
Middle Name:G
Last Name:HALL
Suffix:
Gender:M
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:772 SHADT ST.
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547
Mailing Address - Country:US
Mailing Address - Phone:850-883-1221
Mailing Address - Fax:
Practice Address - Street 1:EGLIN AIR FORCE BASE
Practice Address - Street 2:728TH ACS
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:32542
Practice Address - Country:US
Practice Address - Phone:250-883-1221
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-22
Last Update Date:2009-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1710I1003X1710I1003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians