Provider Demographics
NPI:1265499859
Name:HART, TAMMY K (MD)
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:K
Last Name:HART
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 N FULLERTON ST
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:MO
Mailing Address - Zip Code:64673-1418
Mailing Address - Country:US
Mailing Address - Phone:660-748-4040
Mailing Address - Fax:660-748-4042
Practice Address - Street 1:400 N FULLERTON ST
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:MO
Practice Address - Zip Code:64673-1418
Practice Address - Country:US
Practice Address - Phone:660-748-4040
Practice Address - Fax:660-748-4042
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-27
Last Update Date:2010-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOMD100333207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOJ120000OtherMEDICARE GROUP NUMBER
MO593909203Medicaid
MO10001195600OtherCOMMUNITY HEALTH PLAN
MO203716626Medicaid
MO240969OtherFREEDOM NETWORK
MO20710041OtherBCBS
MO203716626Medicaid
MOF16960Medicare UPIN
MO593909203Medicaid