MEDICARE: ROBERT JAMES HARTKE PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TR0400X	Rehabilitation Psychologist	071-003024	IL
2	103TC1900X	Counseling Psychologist	071-003024	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1673046	OTHER	IL	BLUE CROSS/BLUE SHIELD

General Provider Information

NPI Number	:	1255344628
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROBERT JAMES HARTKE PH.D.

Provider Business Mailing Address
First Line	:	829 REBA PL
Second Line	:
City	:	EVANSTON
State	:	IL
Zip	:	60202-2618
Country	:	US
Telephone Number	:	847-866-7249
Fax Number	:

Provider Business Practice Location Address
First Line	:	636 CHURCH ST
Second Line	:	STE 617
City	:	EVANSTON
State	:	IL
Zip	:	60201-4586
Country	:	US
Telephone Number	:	847-866-7249
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/15/2006
Last Update Date	:	08/07/2016

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