Basic Information
| Provider Information | |||||||||
| NPI: | 1154300770 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HART | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2605 E CREEKS EDGE DR | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 474018368 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123552300 | ||||||||
| FaxNumber: | 8123552316 | ||||||||
| Practice Location | |||||||||
| Address1: | 2605 E CREEKS EDGE DR | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 474018368 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123552300 | ||||||||
| FaxNumber: | 8123552316 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/12/2006 | ||||||||
| LastUpdateDate: | 09/09/2010 | ||||||||
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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 | 207P00000X | 01039715 | IN | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207Q00000X | 01039715A | IN | Y | Allopathic & Osteopathic Physicians | Family Medicine | 208M00000X | 01039715A | IN | N | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 200008900 | 05 | IN | MEDICAID |