Provider Demographics
NPI:1619951258
Name:HANLY, MARK G (MBCHB, FRCPATHLOND)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:G
Last Name:HANLY
Suffix:
Gender:M
Credentials:MBCHB, FRCPATHLOND
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 30309
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29417-0309
Mailing Address - Country:US
Mailing Address - Phone:843-554-9300
Mailing Address - Fax:843-566-8780
Practice Address - Street 1:203 INDIGO DR
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31525-6865
Practice Address - Country:US
Practice Address - Phone:912-261-2669
Practice Address - Fax:912-261-0561
Is Sole Proprietor?:No
Enumeration Date:2005-12-06
Last Update Date:2011-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA035181207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000638206BMedicaid
GA000638206BMedicaid
GA22BDCRJMedicare PIN
GA220021219Medicare PIN