MEDICARE: MR. MARK ALAN HARTLEY MPAS PA-C

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	363AM0700X	Medical Physician Assistant	1033608	GA

General Provider Information

NPI Number	:	1124027685
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MARK ALAN HARTLEY MPAS PA-C

Provider Business Mailing Address
First Line	:	1063 LEE ROAD 338
Second Line	:
City	:	SALEM
State	:	AL
Zip	:	36874-1219
Country	:	US
Telephone Number	:	706-761-8293
Fax Number	:

Provider Business Practice Location Address
First Line	:	7950 MARTIN LOOP
Second Line	:	MARTIN ARMY COMMUNITY HOSPITAL
City	:	FORT BENNING
State	:	GA
Zip	:	31905-5647
Country	:	US
Telephone Number	:	706-545-8543
Fax Number	:

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

Provider Enumeration Date	:	07/18/2005
Last Update Date	:	10/26/2011

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