Provider Demographics
NPI:1578695359
Name:HARTMAN, MARK ALLAN (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ALLAN
Last Name:HARTMAN
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:PO BOX 2116
Mailing Address - Street 2:
Mailing Address - City:SCOTTSBLUFF
Mailing Address - State:NE
Mailing Address - Zip Code:69363-2116
Mailing Address - Country:US
Mailing Address - Phone:308-630-1716
Mailing Address - Fax:308-630-1445
Practice Address - Street 1:3911 AVENUE B
Practice Address - Street 2:SUITE G-100
Practice Address - City:SCOTTSBLUFF
Practice Address - State:NE
Practice Address - Zip Code:69361-4617
Practice Address - Country:US
Practice Address - Phone:308-630-1348
Practice Address - Fax:308-630-1445
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE192192085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE91181806900Medicaid
269459Medicare ID - Type Unspecified
NE91181806900Medicaid
920003740Medicare ID - Type UnspecifiedRAILROAD MEDICARE