Provider Demographics
NPI:1346204229
Name:HART, JERRY T (MD)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:T
Last Name:HART
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 1:1717 HIGH ST
Mailing Address - Street 2:SUITE 4A
Mailing Address - City:HOPKINSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42240-6300
Mailing Address - Country:US
Mailing Address - Phone:270-887-9058
Mailing Address - Fax:270-887-9341
Practice Address - Street 1:1717 HIGH ST
Practice Address - Street 2:SUITE 4A
Practice Address - City:HOPKINSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42240-6300
Practice Address - Country:US
Practice Address - Phone:270-887-9058
Practice Address - Fax:270-887-9341
Is Sole Proprietor?:No
Enumeration Date:2006-04-17
Last Update Date:2014-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY17695207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64176951Medicaid
611385629OtherTIN
KY0665602Medicare ID - Type Unspecified
611385629OtherTIN