Healthcare Provider Details

I. General information

NPI: 1033612528
Provider Name (Legal Business Name): BERNARD LAMAR HARDY II MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/12/2018
Last Update Date: 08/26/2024
Certification Date: 08/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2651 E DISCOVERY PKWY
BLOOMINGTON IN
47408-9059
US

IV. Provider business mailing address

24811 RENSSELAER ST
OAK PARK MI
48237-1773
US

V. Phone/Fax

Practice location:
  • Phone: 812-676-4102
  • Fax: 812-676-4106
Mailing address:
  • Phone: 424-251-1393
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number5315226945
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number4351048740
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number01094213A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: