Jackson Derek Hartley, M.D.

Primary specialty

Internal Medicine PhysicianTaxonomy code 207R00000X

License

LL92431 Issued in SC

Practice address

876 W Faris Rd
Greenville, SC 29605-4253

Phone

(864) 455-5648

NPI assigned

Mar 28, 2024

Sex

Male

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in SC

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Medicine

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1711584000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1723161600000",
    "number": "1104677202",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "876 W FARIS RD",
            "city": "GREENVILLE",
            "state": "SC",
            "postal_code": "296054253"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "876 W FARIS RD",
            "city": "GREENVILLE",
            "state": "SC",
            "postal_code": "296054253",
            "telephone_number": "864-455-5648"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "HARTLEY",
        "first_name": "JACKSON",
        "middle_name": "DEREK",
        "credential": "M.D.",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2024-03-28",
        "last_updated": "2024-08-09",
        "certification_date": "2024-08-09",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207R00000X",
            "taxonomy_group": "",
            "desc": "Internal Medicine",
            "state": "SC",
            "license": "LL92431",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Caroline Hart, PA-C
• Jane A. Hart, CRNA
• John Hart, D.C.
• Morgan Onley Hart, AGACNP-BC
• Amanda Galloway Hartke, MD, PHD
• Lawrence Justin Hartley Jr., MD
• Zora Wilson Hartley, RN
• M Evelyn Hartman, MSN, NP
• Karen R Hartney, PT
• Paulina Hartney, NBC-HWC

• All providers in Greenville, SC
• Internal Medicine Physician in South Carolina

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 9, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.