Provider Demographics
NPI:1558368282
Name:HARTMAN, MARY F (CRNA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:F
Last Name:HARTMAN
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1465 SILVER LEAF AVE
Mailing Address - Street 2:
Mailing Address - City:MT ZION
Mailing Address - State:IL
Mailing Address - Zip Code:62549-1780
Mailing Address - Country:US
Mailing Address - Phone:217-422-3350
Mailing Address - Fax:
Practice Address - Street 1:1800 E LAKE SHORE DR
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62521-3810
Practice Address - Country:US
Practice Address - Phone:217-464-2729
Practice Address - Fax:217-464-1693
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-001121367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL205101Medicare ID - Type Unspecified