Provider Demographics
NPI:1184808651
Name:HART, ERYN JENNIFER (DO)
Entity type:Individual
Prefix:DR
First Name:ERYN
Middle Name:JENNIFER
Last Name:HART
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:ERYN
Other - Middle Name:JENNIFER
Other - Last Name:HART DUTTA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:100 MICHIGAN ST NE # MC845
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:25 MICHIGAN ST NE STE 5200
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2572
Practice Address - Country:US
Practice Address - Phone:616-391-3681
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-20
Last Update Date:2024-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101016371207VX0000X, 207VM0101X
WAOP60894155207VM0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal Medicine
No207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2141653Medicaid