=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508954603
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BLUE WATER OB & GYN PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/11/2006
-----------------------------------------------------
Last Update Date | 09/10/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1313 STONE ST
-----------------------------------------------------
City | PORT HURON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48060-3520
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 810-984-3559
-----------------------------------------------------
Fax | 810-985-5196
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1313 STONE ST
-----------------------------------------------------
City | PORT HURON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48060-3520
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 810-984-3559
-----------------------------------------------------
Fax | 810-985-5196
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. ERIC JAMES HARTMAN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 810-984-3559
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------