1174518617 NPI number — DR. ROBERT MICHAEL HARDY OD

Table of content: DR. ROBERT MICHAEL HARDY OD (NPI 1174518617)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174518617 NPI number — DR. ROBERT MICHAEL HARDY OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HARDY
Provider First Name:
ROBERT
Provider Middle Name:
MICHAEL
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
OD
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:
1174518617
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/29/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
105 W EXCHANGE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPRING LAKE
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49456-2024
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
616-846-0620
Provider Business Mailing Address Fax Number:
616-844-6079

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1231 W MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FREMONT
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49412-1484
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
231-924-2700
Provider Business Practice Location Address Fax Number:
231-924-9255
Provider Enumeration Date:
09/12/2005

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: 152W00000X , with the licence number:  4901002366 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 4956685 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 204829649 . This is a "TAX ID" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 5175725 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 383628290 . This is a "TAX ID" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 900F111210 . This is a "BCBS OF MICHIGAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4901002366 . This is a "STATE LICENSE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4964990 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 201249427 . This is a "TAX ID" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 202916337 . This is a "TAX ID" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: U37641 . This is a "UPIN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 900F210170 . This is a "BCBS OF MICHIGAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com