Provider Demographics
NPI:1205410784
Name:SALLY M HARTWICK, MD PLLC
Entity Type:Organization
Organization Name:SALLY M HARTWICK, MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SALLY
Authorized Official - Middle Name:
Authorized Official - Last Name:HARTWICK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:607-639-2701
Mailing Address - Street 1:25 EVERGREEN ST
Mailing Address - Street 2:
Mailing Address - City:AFTON
Mailing Address - State:NY
Mailing Address - Zip Code:13730-2129
Mailing Address - Country:US
Mailing Address - Phone:607-639-2701
Mailing Address - Fax:607-639-3333
Practice Address - Street 1:25 EVERGREEN ST
Practice Address - Street 2:
Practice Address - City:AFTON
Practice Address - State:NY
Practice Address - Zip Code:13730-2129
Practice Address - Country:US
Practice Address - Phone:607-316-1576
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-10
Last Update Date:2021-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1275023020OtherTYPE 1 NPI