Basic Information
| Provider Information | |||||||||
| NPI: | 1285655035 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HARTLEY | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 75868 | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212755868 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7033836469 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1850 TOWN CENTER PKWY | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | RESTON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 201903219 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7038105202 | ||||||||
| FaxNumber: | 7037879664 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2006 | ||||||||
| LastUpdateDate: | 10/26/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/26/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 0101041921 | VA | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | DC1555 | 01 | MEDICARE RAILROAD GROUP | OTHER | 6402038 | 05 | VA | MEDICAID | P00151220 | 01 | MEDICARE RAILROAD | OTHER |