Provider Demographics
NPI:1457357642
Name:HART, ROY ALDEN (DO)
Entity Type:Individual
Prefix:
First Name:ROY
Middle Name:ALDEN
Last Name:HART
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1801 HICKMAN ROAD
Mailing Address - Street 2:BROADLAWNS MEDICAL CENTER
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50314
Mailing Address - Country:US
Mailing Address - Phone:515-282-2548
Mailing Address - Fax:
Practice Address - Street 1:1801 HICKMAN ROAD
Practice Address - Street 2:BROADLAWNS MEDICAL CENTER
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50314
Practice Address - Country:US
Practice Address - Phone:515-282-2548
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036081158174400000X
MI5315029112207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA01967OtherLICENSE NUMBER
MI5315029112OtherSTATE LICENSE
MIRH007937OtherLICENSE
MI114945064Medicaid
MI160G360190OtherBCBSM GROUP PIN
IL036021158Medicaid
MI381870664OtherTAX ID
IL036021158Medicaid
MI381870664OtherTAX ID
MI0G36019041Medicare PIN
ILA02146Medicare UPIN