Provider Demographics
NPI:1174518617
Name:HARDY, ROBERT MICHAEL (OD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:MICHAEL
Last Name:HARDY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 W EXCHANGE ST
Mailing Address - Street 2:
Mailing Address - City:SPRING LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:49456-2024
Mailing Address - Country:US
Mailing Address - Phone:616-846-0620
Mailing Address - Fax:616-844-6079
Practice Address - Street 1:1231 W MAIN ST
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:MI
Practice Address - Zip Code:49412-1484
Practice Address - Country:US
Practice Address - Phone:231-924-2700
Practice Address - Fax:231-924-9255
Is Sole Proprietor?:No
Enumeration Date:2005-09-12
Last Update Date:2009-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002366152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4956685Medicaid
MI204829649OtherTAX ID
MI5175725Medicaid
MI383628290OtherTAX ID
MI900F111210OtherBCBS OF MICHIGAN
MI4901002366OtherSTATE LICENSE
MI4964990Medicaid
MI201249427OtherTAX ID
MI202916337OtherTAX ID
MIU37641OtherUPIN
MI900F210170OtherBCBS OF MICHIGAN
MI0P32620Medicare PIN
MI5175725Medicaid
MI0P21400Medicare PIN
MIU37641OtherUPIN
MI383628290OtherTAX ID
MI4956685Medicaid
MI5189400016Medicare PIN
MI0P13290Medicare ID - Type UnspecifiedMEDICARE PART B GROUP