Basic Information
| Provider Information | |||||||||
| NPI: | 1114938453 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HARTSOCK | ||||||||
| FirstName: | STEPHEN | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 250 N SHADELAND AVE | ||||||||
| Address2: | STE 130 - PROVIDER ENROLLMENT | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462194959 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1115 RONALD REAGAN PKWY | ||||||||
| Address2: | STE 148 | ||||||||
| City: | AVON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461236910 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3179628893 | ||||||||
| FaxNumber: | 3179626722 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2006 | ||||||||
| LastUpdateDate: | 03/25/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 036110046 | IL | N | Other Service Providers | Specialist | 207Q00000X | 01072804A | IN | N | Allopathic & Osteopathic Physicians | Family Medicine | 207QS0010X | 01072804A | IN | Y | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | 336070768 | 01 | IL | CONTROLLED SUBSTANCE # | OTHER | 201166240 | 05 | IN | MEDICAID | BH8994003 | 01 | IL | DEA # | OTHER |