Healthcare Provider Details

I. General information

NPI: 1639565583
Provider Name (Legal Business Name): BROCK ANDREW HARDIN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2015
Last Update Date: 09/26/2024
Certification Date: 09/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2490 S 11TH ST STE 201
KALAMAZOO MI
49009-2175
US

IV. Provider business mailing address

2490 S 11TH ST STE 201
KALAMAZOO MI
49009-2175
US

V. Phone/Fax

Practice location:
  • Phone: 269-343-1535
  • Fax:
Mailing address:
  • Phone: 269-343-1535
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number4301504273
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: