Provider Demographics
NPI:1366496499
Name:HARTMANN, JOHN (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:HARTMANN
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 1:200 JEFFERSON AVE SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-4502
Mailing Address - Country:US
Mailing Address - Phone:616-685-1808
Mailing Address - Fax:616-685-8099
Practice Address - Street 1:309 JEFFERSON AVE SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4503
Practice Address - Country:US
Practice Address - Phone:616-685-8750
Practice Address - Fax:616-685-8002
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2015-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301042335207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4877302Medicaid
MI3105688Medicaid
MI4108728Medicaid
MI2901060Medicaid
MI3105688Medicaid
MIP32930077Medicare ID - Type Unspecified
MI3105688Medicaid
MIM69390049Medicare ID - Type Unspecified