Provider Demographics
NPI:1760434559
Name:HAWLEY, MARY LYNNE (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:LYNNE
Last Name:HAWLEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:LYNNE
Other - Last Name:DETLING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:5735 MEEKER RD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45331-1180
Mailing Address - Country:US
Mailing Address - Phone:937-548-9680
Mailing Address - Fax:937-548-2087
Practice Address - Street 1:5735 MEEKER RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:OH
Practice Address - Zip Code:45331-1180
Practice Address - Country:US
Practice Address - Phone:937-548-9680
Practice Address - Fax:937-548-2087
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35069759D208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2012253Medicaid
OHDE7247251Medicare ID - Type Unspecified
OHG73177Medicare UPIN