1760453211 NPI number — MR. MARK HUNTLEY MD

Table of content: MR. MARK HUNTLEY MD (NPI 1760453211)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760453211 NPI number — MR. MARK HUNTLEY MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HUNTLEY
Provider First Name:
MARK
Provider Middle Name:
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1760453211
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/18/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5665 NEW NORTHSIDE DR
Provider Second Line Business Mailing Address:
SUITE 320 SPARTANBURG EMERGENCY PHYSICIANS, LLC
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30384-1431
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-847-6803
Provider Business Mailing Address Fax Number:
770-847-6833

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1700 SKYLYN DRIVE
Provider Second Line Business Practice Location Address:
SPARTANBURG EMERGENCY PHYSICIANS, LLC
Provider Business Practice Location Address City Name:
SPARTANGBURG
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29307-1041
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-874-6803
Provider Business Practice Location Address Fax Number:
770-874-6833
Provider Enumeration Date:
01/31/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208D00000X , with the licence number:  16177 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207P00000X , with the licence number: 16177 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 89063KU , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 161773 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".