Provider Demographics
NPI:1689716680
Name:JACK HARTLEY MD PC
Entity Type:Organization
Organization Name:JACK HARTLEY MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JACK
Authorized Official - Middle Name:
Authorized Official - Last Name:HARTLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:541-548-7761
Mailing Address - Street 1:1523 NW CANAL BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:REDMOND
Mailing Address - State:OR
Mailing Address - Zip Code:97756-1340
Mailing Address - Country:US
Mailing Address - Phone:541-548-7761
Mailing Address - Fax:541-526-6554
Practice Address - Street 1:1523 NW CANAL BLVD STE 200
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:OR
Practice Address - Zip Code:97756-1340
Practice Address - Country:US
Practice Address - Phone:541-548-7761
Practice Address - Fax:541-526-6554
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD12789174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty