Provider Demographics
NPI:1356319149
Name:HARTLE, MARCY A (MD)
Entity type:Individual
Prefix:DR
First Name:MARCY
Middle Name:A
Last Name:HARTLE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 HOSPITAL AVE
Mailing Address - Street 2:
Mailing Address - City:DU BOIS
Mailing Address - State:PA
Mailing Address - Zip Code:15801-1440
Mailing Address - Country:US
Mailing Address - Phone:814-371-1510
Mailing Address - Fax:814-371-2922
Practice Address - Street 1:865 BEAVER DR
Practice Address - Street 2:
Practice Address - City:DU BOIS
Practice Address - State:PA
Practice Address - Zip Code:15801
Practice Address - Country:US
Practice Address - Phone:814-371-1510
Practice Address - Fax:814-371-2922
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-09
Last Update Date:2019-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD453017208000000X
NY1618772080A0000X
FLME161877208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY016848817Medicaid
FL101066300Medicaid
NY161424641OtherAETNA
NY016848817Medicaid
NY101092DLOtherPREFFERED CARE OF ROCHEST
NY161424641OtherUNITED HEALTH CARE
NY00092635501OtherBC BS OF WESTERN NY
NY2448OtherBC/BS OF ROCHESTER