Provider Demographics
NPI:1033143953
Name:HARTLEY, SUSAN (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:HARTLEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1610 BROADRICK DR
Mailing Address - Street 2:
Mailing Address - City:DALTON
Mailing Address - State:GA
Mailing Address - Zip Code:30720-3012
Mailing Address - Country:US
Mailing Address - Phone:706-279-1994
Mailing Address - Fax:
Practice Address - Street 1:1610 BROADRICK DR
Practice Address - Street 2:
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30720-3012
Practice Address - Country:US
Practice Address - Phone:706-279-1994
Practice Address - Fax:706-279-9229
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2017-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA065257208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA813405133DMedicaid
SCAA14763640Medicare PIN
SCAA14767951Medicare PIN
SC576007863102OtherBCBS