Provider Demographics
NPI:1235116583
Name:HARTWICK, RUSSELL ALBERT JR (DO)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:ALBERT
Last Name:HARTWICK
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 190
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:OH
Mailing Address - Zip Code:45640-0190
Mailing Address - Country:US
Mailing Address - Phone:740-577-9181
Mailing Address - Fax:740-577-9214
Practice Address - Street 1:500 BURLINGTON RD
Practice Address - Street 2:STE 260
Practice Address - City:JACKSON
Practice Address - State:OH
Practice Address - Zip Code:45640-9360
Practice Address - Country:US
Practice Address - Phone:740-577-9181
Practice Address - Fax:740-577-9214
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2016-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34005013207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0789893Medicaid
H422751Medicare PIN
OH0789893Medicaid