MEDICARE: CARLY HARTMAN ATC, LAT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer	AT005390	OH

General Provider Information

NPI Number	:	1104457829
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CARLY HARTMAN ATC, LAT

Provider Business Mailing Address
First Line	:	5308 ORCHARD PARK DR
Second Line	:
City	:	PARMA
State	:	OH
Zip	:	44134-4514
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5308 ORCHARD PARK DR
Second Line	:
City	:	PARMA
State	:	OH
Zip	:	44134-4514
Country	:	US
Telephone Number	:	330-620-5942
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/31/2020
Last Update Date	:	01/31/2020

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