Healthcare Provider Details

I. General information

NPI: 1306468889
Provider Name (Legal Business Name): AMBER DALE HARTMAN DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMBER DALE RUSSO

II. Dates (important events)

Enumeration Date: 05/07/2020
Last Update Date: 06/21/2023
Certification Date: 06/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 N 9TH ST # 4A
SPRINGFIELD IL
62702-5310
US

IV. Provider business mailing address

PO BOX 19639
SPRINGFIELD IL
62794-9639
US

V. Phone/Fax

Practice location:
  • Phone: 217-545-8000
  • Fax: 217-545-4779
Mailing address:
  • Phone: 217-545-8000
  • Fax: 217-545-2101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036164848
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2080P0006X
TaxonomyDevelopmental - Behavioral Pediatrics Physician
License Number036164848
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: