Basic Information
| Provider Information | |||||||||
| NPI: | 1164437455 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HART | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | BRIDGET | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1400 S ORANGE AVE | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328062134 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4076483800 | ||||||||
| FaxNumber: | 4074255203 | ||||||||
| Practice Location | |||||||||
| Address1: | 1400 S ORANGE AVE | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328062134 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4076483800 | ||||||||
| FaxNumber: | 4074255203 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2006 | ||||||||
| LastUpdateDate: | 06/21/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085N0904X | ME0064493 | FL | N | Allopathic & Osteopathic Physicians | Radiology | Nuclear Radiology | 2085R0202X | ME0064493 | FL | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0203X | ME0064493 | FL | N | Allopathic & Osteopathic Physicians | Radiology | Therapeutic Radiology | 207U00000X | ME0064493 | FL | Y | Allopathic & Osteopathic Physicians | Nuclear Medicine |
ID Information
| ID | Type | State | Issuer | Description | 360003245 | 01 | MEDICARE RR | OTHER | 23058 | 01 | FL | BCBS | OTHER | 3805400 | 01 | UNITED HEALTH CARE | OTHER | 373223100 | 05 | FL | MEDICAID |