=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033612528
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BERNARD LAMAR HARDY II MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/12/2018
-----------------------------------------------------
Last Update Date | 08/26/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2651 E DISCOVERY PKWY
-----------------------------------------------------
City | BLOOMINGTON
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47408-9059
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-676-4102
-----------------------------------------------------
Fax | 812-676-4106
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 24811 RENSSELAER ST
-----------------------------------------------------
City | OAK PARK
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48237-1773
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 424-251-1393
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number | 5315226945
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number | 4351048740
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 01094213A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------