Basic Information
| Provider Information | |||||||||
| NPI: | 1083635700 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HARTJES | ||||||||
| FirstName: | THOMAS | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 833 S IOWA ST | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | DODGEVILLE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 535331900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6089353301 | ||||||||
| FaxNumber: | 6089353823 | ||||||||
| Practice Location | |||||||||
| Address1: | 2402 WINNEBAGO ST | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 537045341 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6082426855 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 26314 | WI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 30633500 | 05 | WI | MEDICAID |