Provider Demographics
NPI:1477522142
Name:HART, ANDREW R (MD)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:R
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 1:12633 SURREY ST
Mailing Address - Street 2:
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55347-2866
Mailing Address - Country:US
Mailing Address - Phone:765-491-3455
Mailing Address - Fax:
Practice Address - Street 1:15450 HIGHWAY 7 STE 100
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55345-3522
Practice Address - Country:US
Practice Address - Phone:763-581-8900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN72806207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100097630Medicaid
IN10825227OtherCAQH NUMBER
IN000000192403OtherANTHEM PROVIDER NUMBER
IN9397120OtherPHCS PID NUMBER
IN815460IIIIMedicare PIN
IN110166361Medicare PIN
IN000000192403OtherANTHEM PROVIDER NUMBER
IN815500HMedicare PIN