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NPI Code Detail

MEDICARE: DR. NICOLE ANN HARTSOUGH M.D.

MEDICARE: DR. NICOLE ANN HARTSOUGH M.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
1207N00000XDermatology PhysicianIL

General Provider Information

NPI Number : 1962400382
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. NICOLE ANN HARTSOUGH M.D.
Provider Business Mailing Address
First Line : 7402 E RIVERSIDE BLVD
Second Line :
City : LOVES PARK
State : IL
Zip : 61111-5630
Country : US
Telephone Number : 815-226-9642
Fax Number : 815-226-9672
Provider Business Practice Location Address
First Line : 7402 E RIVERSIDE BLVD
Second Line :
City : LOVES PARK
State : IL
Zip : 61111-5630
Country : US
Telephone Number : 815-226-9642
Fax Number : 815-226-9672
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/10/2005
Last Update Date : 10/18/2007

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