Basic Information
| Provider Information | |||||||||
| NPI: | 1760475727 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HARTLEY | ||||||||
| FirstName: | BRENDA | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HARTLEY-DYMARKOWSKI | ||||||||
| OtherFirstName: | BRENDA | ||||||||
| OtherMiddleName: | M | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5700 MONROE ST UNIT 301 | ||||||||
| Address2: | |||||||||
| City: | SYLVANIA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 435602737 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192912121 | ||||||||
| FaxNumber: | 4194796017 | ||||||||
| Practice Location | |||||||||
| Address1: | 5700 MONROE ST UNIT 301 | ||||||||
| Address2: | |||||||||
| City: | SYLVANIA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 435602737 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192912121 | ||||||||
| FaxNumber: | 4194796017 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2005 | ||||||||
| LastUpdateDate: | 11/08/2017 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 35064035 | OH | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 10717 | 01 | OH | HPM | OTHER | 12-03667 | 01 | MI | UHC | OTHER | 3505802301 | 01 | MI | BCBS MI | OTHER | 4530886 | 01 | MI | AETNA | OTHER | 0997711 | 01 | OH | BCMH | OTHER | 0637659 | 01 | OH | AETNA | OTHER | 01872 | 01 | OH | PHC | OTHER | 000000141209 | 01 | OH | ANTHEM | OTHER | 12-01238 | 01 | OH | UHC | OTHER | 370012698 | 01 | OH | RRMC | OTHER | 000000217929 | 01 | MI | ANTHEM | OTHER | 0997711 | 05 | OH | MEDICAID |