1366419814 NPI number — PETER B HARDIN MD

Table of content: PETER B HARDIN MD (NPI 1366419814)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366419814 NPI number — PETER B HARDIN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HARDIN
Provider First Name:
PETER
Provider Middle Name:
B
Provider Name Prefix Text:
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:
1366419814
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/01/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
125 GREENBRIAR DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CAMPBELLSVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
42718-9616
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
270-789-9999
Provider Business Mailing Address Fax Number:
270-789-0247

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
125 GREENBRIAR DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CAMPBELLSVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42718-9616
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-789-9999
Provider Business Practice Location Address Fax Number:
270-789-0247
Provider Enumeration Date:
03/03/2006

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: 2085R0001X , with the licence number:  4301081290 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0001X , with the licence number: 42374 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 104495980 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: C55045 . This is a "CUMBERLAND HEALTHCARE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 1366419814 . This is a "TRICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 7100060870 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000664006 . This is a "ANTHEM" identifier . This identifiers is of the category "OTHER".
  • Identifier: 50028881 . This is a "PASSPORT HEALTH PLAN/PASSPORT ADVANTAGE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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