Provider Demographics
NPI:1760453211
Name:HUNTLEY, MARK (MD)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:HUNTLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5665 NEW NORTHSIDE DR
Mailing Address - Street 2:SUITE 320 SPARTANBURG EMERGENCY PHYSICIANS, LLC
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-1431
Mailing Address - Country:US
Mailing Address - Phone:770-847-6803
Mailing Address - Fax:770-847-6833
Practice Address - Street 1:1700 SKYLYN DRIVE
Practice Address - Street 2:SPARTANBURG EMERGENCY PHYSICIANS, LLC
Practice Address - City:SPARTANGBURG
Practice Address - State:SC
Practice Address - Zip Code:29307-1041
Practice Address - Country:US
Practice Address - Phone:770-874-6803
Practice Address - Fax:770-874-6833
Is Sole Proprietor?:No
Enumeration Date:2006-01-31
Last Update Date:2012-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC16177208D00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89063KUMedicaid
SC161773Medicaid