Healthcare Provider Details

I. General information

NPI: 1093060584
Provider Name (Legal Business Name): JAMIE HARDMAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2012
Last Update Date: 05/05/2021
Certification Date: 05/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 MEMORIAL DR STE 210
ALTON IL
62002
US

IV. Provider business mailing address

4 MEMORIAL DR STE 210
ALTON IL
62002-6751
US

V. Phone/Fax

Practice location:
  • Phone: 618-463-5905
  • Fax: 618-463-5935
Mailing address:
  • Phone: 618-463-5905
  • Fax: 618-463-5935

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number036141760
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: