Provider Demographics
NPI:1245641489
Name:MERTZ-HACK, TARA RENAE (MD)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:RENAE
Last Name:MERTZ-HACK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:RENAE
Other - Last Name:MERTZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9990 HIGHWAY 11
Mailing Address - Street 2:
Mailing Address - City:OAKES
Mailing Address - State:ND
Mailing Address - Zip Code:58474-9171
Mailing Address - Country:US
Mailing Address - Phone:702-210-0140
Mailing Address - Fax:
Practice Address - Street 1:420 S 7TH ST
Practice Address - Street 2:
Practice Address - City:OAKES
Practice Address - State:ND
Practice Address - Zip Code:58474-2024
Practice Address - Country:US
Practice Address - Phone:701-742-3267
Practice Address - Fax:701-742-3201
Is Sole Proprietor?:No
Enumeration Date:2014-05-09
Last Update Date:2019-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMRM-1396207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine