Provider Demographics
NPI:1881031151
Name:JEFFREY HARTZELL MD PC
Entity Type:Organization
Organization Name:JEFFREY HARTZELL MD PC
Other - Org Name:INDIANA SPORTS MEDICINE AND ORTHOPAEDICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:HARTZELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:260-205-5634
Mailing Address - Street 1:10214 CHESTNUT PLAZA DR
Mailing Address - Street 2:#231
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46814-8970
Mailing Address - Country:US
Mailing Address - Phone:260-205-5634
Mailing Address - Fax:
Practice Address - Street 1:2936 FRONTAGE RD
Practice Address - Street 2:
Practice Address - City:WARSAW
Practice Address - State:IN
Practice Address - Zip Code:46580-3914
Practice Address - Country:US
Practice Address - Phone:260-205-5634
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-28
Last Update Date:2014-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201163670AMedicaid
IN201163670AMedicaid