Provider Demographics
NPI:1477525723
Name:HART, MICHAEL (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:HART
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 1:450 KYLES MILL RD
Mailing Address - Street 2:
Mailing Address - City:BUCHANAN
Mailing Address - State:VA
Mailing Address - Zip Code:24066-5004
Mailing Address - Country:US
Mailing Address - Phone:540-473-1274
Mailing Address - Fax:
Practice Address - Street 1:102 HIGHLAND AVE SE
Practice Address - Street 2:SUITE 305
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24013-2256
Practice Address - Country:US
Practice Address - Phone:540-985-9832
Practice Address - Fax:540-224-4421
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2011-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101-057411208000000X, 2080P0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric Gastroenterology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1477525723Medicaid
VA6701477Medicaid
VA010097037Medicaid
VA010378567Medicaid
000054C19Medicare PIN
VA010378567Medicaid