MEDICARE: DR. RODERIC JOEL HARTMAN 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
1	208000000X	Pediatrics Physician	G87523	CA
2	208000000X	Pediatrics Physician	21315	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	651170616	OTHER	AZ	TAX ID
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1962607317
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RODERIC JOEL HARTMAN M.D.

Provider Business Mailing Address
First Line	:	PO BOX 1669
Second Line	:	1896 E BABBITT LANE
City	:	SAN LUIS
State	:	AZ
Zip	:	85349-1669
Country	:	US
Telephone Number	:	928-722-6112
Fax Number	:	928-722-6113

Provider Business Practice Location Address
First Line	:	1896 E BABBITT LANE
Second Line	:
City	:	SAN LUIS
State	:	AZ
Zip	:	85349-1669
Country	:	US
Telephone Number	:	928-722-6112
Fax Number	:	928-722-6113

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/17/2007
Last Update Date	:	10/03/2016

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