Provider Demographics
NPI:1508029844
Name:HART FAMILY MEDICINE PLLC
Entity Type:Organization
Organization Name:HART FAMILY MEDICINE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING/SUPPORT
Authorized Official - Prefix:
Authorized Official - First Name:BRANDI
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-466-3960
Mailing Address - Street 1:107 E HOLLAND AVE
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99218-1209
Mailing Address - Country:US
Mailing Address - Phone:509-466-3960
Mailing Address - Fax:509-466-9566
Practice Address - Street 1:107 E HOLLAND AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99218-1209
Practice Address - Country:US
Practice Address - Phone:509-466-3960
Practice Address - Fax:509-466-9566
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-07
Last Update Date:2010-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP00001655207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1124858Medicaid
WA0229080OtherWA DEPT OF LABOR
WA0229080OtherWA DEPT OF LABOR