Provider Demographics
NPI:1285655035
Name:HARTLEY, MARK C (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:C
Last Name:HARTLEY
Suffix:
Gender:M
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:PO BOX 75868
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21275-5868
Mailing Address - Country:US
Mailing Address - Phone:703-383-6469
Mailing Address - Fax:
Practice Address - Street 1:1850 TOWN CENTER PKWY
Practice Address - Street 2:SUITE 400
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20190-3219
Practice Address - Country:US
Practice Address - Phone:703-810-5202
Practice Address - Fax:703-787-9664
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101041921207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC1555OtherMEDICARE RAILROAD GROUP
VA6402038Medicaid
P00151220OtherMEDICARE RAILROAD
MC11437Medicare PIN
VA6402038Medicaid
E36935Medicare UPIN
DC1555OtherMEDICARE RAILROAD GROUP
C10465Medicare PIN