Basic Information
| Provider Information | |||||||||
| NPI: | 1902854474 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HARTMAN | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7112 | ||||||||
| Address2: | DPT 31 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462077112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3178023151 | ||||||||
| FaxNumber: | 3178700499 | ||||||||
| Practice Location | |||||||||
| Address1: | 1600 ALBANY ST | ||||||||
| Address2: | |||||||||
| City: | BEECH GROVE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461071541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3178023151 | ||||||||
| FaxNumber: | 3178700499 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2006 | ||||||||
| LastUpdateDate: | 07/21/2009 | ||||||||
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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 | 146D00000X | 35087317 | OH | Y | Emergency Medical Service Providers | Personal Emergency Response Attendant |
ID Information
| ID | Type | State | Issuer | Description | 200855290 | 05 | IN | MEDICAID |