Basic Information
| Provider Information | |||||||||
| NPI: | 1356319149 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HARTLE | ||||||||
| FirstName: | MARCY | ||||||||
| MiddleName: | A. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 HOSPITAL AVE | ||||||||
| Address2: | |||||||||
| City: | DU BOIS | ||||||||
| State: | PA | ||||||||
| PostalCode: | 158011440 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8143711510 | ||||||||
| FaxNumber: | 8143712922 | ||||||||
| Practice Location | |||||||||
| Address1: | 865 BEAVER DR | ||||||||
| Address2: | |||||||||
| City: | DU BOIS | ||||||||
| State: | PA | ||||||||
| PostalCode: | 15801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8143711510 | ||||||||
| FaxNumber: | 8143712922 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2006 | ||||||||
| LastUpdateDate: | 10/29/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | MD453017 | PA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 2080A0000X | 161877 | NY | N | Allopathic & Osteopathic Physicians | Pediatrics | Adolescent Medicine | 208000000X | ME161877 | FL | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 016848817 | 05 | NY | MEDICAID | 101066300 | 05 | FL | MEDICAID |