MEDICARE: BLUE WATER OB & GYN PC

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	207V00000X	Obstetrics & Gynecology Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0G46050	OTHER	MI	BCBSMI

General Provider Information

NPI Number	:	1508954603
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLUE WATER OB & GYN PC

Provider Business Mailing Address
First Line	:	1313 STONE ST
Second Line	:
City	:	PORT HURON
State	:	MI
Zip	:	48060-3520
Country	:	US
Telephone Number	:	810-984-3559
Fax Number	:	810-985-5196

Provider Business Practice Location Address
First Line	:	1313 STONE ST
Second Line	:
City	:	PORT HURON
State	:	MI
Zip	:	48060-3520
Country	:	US
Telephone Number	:	810-984-3559
Fax Number	:	810-985-5196

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. ERIC JAMES HARTMAN
Credential	:	MD
Telephone Number	:	810-984-3559

Provider Enumeration Date	:	10/11/2006
Last Update Date	:	09/10/2009

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