Provider Demographics
NPI:1376530519
Name:HARLEY, DOUGLAS WAYNE (DO)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:WAYNE
Last Name:HARLEY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:676 SOUTH BROADWAY STREET
Mailing Address - Street 2:CANAL PHYSICIANS GROUP
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44311-1059
Mailing Address - Country:US
Mailing Address - Phone:330-344-4000
Mailing Address - Fax:330-253-2349
Practice Address - Street 1:676 SOUTH BROADWAY STREET
Practice Address - Street 2:CANAL PHYSICIANS GROUP
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44311-1059
Practice Address - Country:US
Practice Address - Phone:330-344-4000
Practice Address - Fax:330-253-2349
Is Sole Proprietor?:No
Enumeration Date:2005-10-03
Last Update Date:2013-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34008403207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3600271OtherCFM MEDICARE GROUP #
OH0290886OtherCFM MEDICAID GROUP #
OH1548207111OtherCFG TYPE 2 NPI #
OH2551671OtherPARTNERS PHYSICIAN GROUP MEDICAID GROUP #
OH9338635OtherPARTNERS PHYSICIAN GROUP MEDICARE GROUP #
OH1821035940OtherAGMC (CFM)TYPE 2 NPI #
OH4177252OtherMEDICARE PTAN (PPG)
OH1841239274OtherPARTNERS PHYSICIAN GROUP TYPE 2 NPI #
OH2555739Medicaid
OH7402171OtherMEDICARE PTAN (CFM)
I27292Medicare UPIN