Healthcare Provider Details

I. General information

NPI: 1669473815
Provider Name (Legal Business Name): ROBERT DAMION HARDISON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2005
Last Update Date: 08/23/2021
Certification Date: 08/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 FOUNDATION DR
FLEMINGSBURG KY
41041-9815
US

IV. Provider business mailing address

9405 LOMAX FOREST DR
MANASSAS VA
20112-4448
US

V. Phone/Fax

Practice location:
  • Phone: 606-849-5000
  • Fax:
Mailing address:
  • Phone: 703-615-4141
  • Fax: 844-605-4187

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number25483
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0101251662
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number46459
License Number StateKY
# 4
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD36862
License Number StateTN
# 5
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number0101251662
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: