Provider Demographics
NPI:1619966256
Name:HARTZELL, THOMAS R (MD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:R
Last Name:HARTZELL
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 1:21000 E 12 MILE RD
Mailing Address - Street 2:STE 102
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48081-1156
Mailing Address - Country:US
Mailing Address - Phone:800-848-0202
Mailing Address - Fax:586-226-6949
Practice Address - Street 1:21000 E 12 MILE RD
Practice Address - Street 2:STE 102
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48081-1156
Practice Address - Country:US
Practice Address - Phone:800-848-0202
Practice Address - Fax:586-226-6949
Is Sole Proprietor?:No
Enumeration Date:2005-10-17
Last Update Date:2019-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301052970207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4755687Medicaid
MIM92780005Medicare PIN
M71670091Medicare ID - Type Unspecified
MI4755687Medicaid