Basic Information
| Provider Information | |||||||||
| NPI: | 1457354201 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HARTWIG | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | DEAN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 505 N 14TH ST | ||||||||
| Address2: | STE C | ||||||||
| City: | PERRY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730775000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5803363529 | ||||||||
| FaxNumber: | 5803362409 | ||||||||
| Practice Location | |||||||||
| Address1: | 505 N 14TH ST | ||||||||
| Address2: | |||||||||
| City: | PERRY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730775021 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5803363529 | ||||||||
| FaxNumber: | 5803362409 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2005 | ||||||||
| LastUpdateDate: | 01/11/2017 | ||||||||
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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 | 16159 | OK | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 731341903 | 01 | OK | TAX ID | OTHER | 100106450A | 05 | OK | MEDICAID |