Provider Demographics
NPI:1265498331
Name:HARTSOUGH, ALLAN R (MD)
Entity Type:Individual
Prefix:
First Name:ALLAN
Middle Name:R
Last Name:HARTSOUGH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 E NICOLLET BLVD
Mailing Address - Street 2:
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55337-4522
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:303 NICOLLET BOULEVARD
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337
Practice Address - Country:US
Practice Address - Phone:952-892-8770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2020-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ20046207V00000X
MN39641207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNB28413Medicare UPIN