Healthcare Provider Details

I. General information

NPI: 1275370942
Provider Name (Legal Business Name): MARY KATHERINE HARTZOG RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2024
Last Update Date: 06/04/2026
Certification Date: 06/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2095 HENRY TECKLENBURG DR
CHARLESTON SC
29414-5733
US

IV. Provider business mailing address

856 BIBURY CT
CHARLESTON SC
29414-9120
US

V. Phone/Fax

Practice location:
  • Phone: 843-792-2300
  • Fax:
Mailing address:
  • Phone: 770-861-8961
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number32033
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number257085
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: