Provider Demographics
NPI:1467670802
Name:MARTY HURLBUT, M.D., PA
Entity Type:Organization
Organization Name:MARTY HURLBUT, M.D., PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:MARTIN
Authorized Official - Last Name:HURLBUT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:479-444-2207
Mailing Address - Street 1:PO BOX 8638
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-0011
Mailing Address - Country:US
Mailing Address - Phone:479-444-2207
Mailing Address - Fax:479-444-2381
Practice Address - Street 1:153 E MONTE PAINTER DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-4002
Practice Address - Country:US
Practice Address - Phone:479-444-2207
Practice Address - Fax:479-444-2381
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2013-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARN8015208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR117736001Medicaid
AR146527002Medicaid
AR=========OtherTAX ID #
AR54076Medicare PIN
AR54076Medicare ID - Type UnspecifiedMEDICARE PROVIDER #
AR117736001Medicaid
AR260047868Medicare PIN