Healthcare Provider Details

I. General information

NPI: 1477597524
Provider Name (Legal Business Name): BRAD LYN HARTWIG PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2006
Last Update Date: 01/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11475 N 2ND ST
MACHESNEY PARK IL
61115-1285
US

IV. Provider business mailing address

1394 KIWANIS DR APT B302
FREEPORT IL
61032-6940
US

V. Phone/Fax

Practice location:
  • Phone: 815-654-8000
  • Fax:
Mailing address:
  • Phone: 815-821-4777
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1167
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085-002982
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: