Provider Demographics
NPI:1093710675
Name:HART FAMILY MEDICAL ASSOCIATES PC
Entity Type:Organization
Organization Name:HART FAMILY MEDICAL ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RUDY
Authorized Official - Middle Name:C
Authorized Official - Last Name:OCHS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:231-873-5675
Mailing Address - Street 1:611 EAST MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HART
Mailing Address - State:MI
Mailing Address - Zip Code:49420-1190
Mailing Address - Country:US
Mailing Address - Phone:231-873-5675
Mailing Address - Fax:231-873-4805
Practice Address - Street 1:611 EAST MAIN ST
Practice Address - Street 2:
Practice Address - City:HART
Practice Address - State:MI
Practice Address - Zip Code:49420-1190
Practice Address - Country:US
Practice Address - Phone:231-873-5675
Practice Address - Fax:231-873-4805
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-20
Last Update Date:2009-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAB03370104100000X
MI207Q00000X
MI5101011414207Q00000X
MI5101011554207Q00000X
MI5101009698207Q00000X
MI4101133105207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3015197 TYPE 11OtherPAUL A WAGNER
MI8008974220OtherBCBS MI
MI500F4710070OtherBCBS NP GROUP NUMBER
MI01027OtherPRIORITY HEALTH GRP #
MI010F476090OtherBCBS GROUP NUMBER
MI4338002 TYPE 11Medicaid
MI11272959OtherCAQH ID NUMBER
MI800F410320OtherBCBSMI
MI01027OtherPRIORITY HEALTH GRP #
MI8008974220OtherBCBS MI
MI500F4710070OtherBCBS NP GROUP NUMBER
MI11272959OtherCAQH ID NUMBER
MI=========OtherTAX ID
MI0F47609Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER
MION44300Medicare PIN
MI01027OtherPRIORITY HEALTH GRP #
MI3269528 TYPE 11Medicare ID - Type UnspecifiedCONSTANCE STRBICH