Provider Demographics
NPI:1760487946
Name:HARTLEY, FREDERICK C (MD)
Entity Type:Individual
Prefix:
First Name:FREDERICK
Middle Name:C
Last Name:HARTLEY
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 1:203 E WATAUGA AVE
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37601-4629
Mailing Address - Country:US
Mailing Address - Phone:423-926-2129
Mailing Address - Fax:423-926-8576
Practice Address - Street 1:203 E WATAUGA AVE
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37601-4629
Practice Address - Country:US
Practice Address - Phone:423-926-2129
Practice Address - Fax:423-926-8576
Is Sole Proprietor?:No
Enumeration Date:2005-06-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN11190207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3173953Medicaid
TNB03632Medicare UPIN
TN3173953Medicaid