Provider Demographics
NPI:1366419814
Name:HARDIN, PETER B (MD)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:B
Last Name:HARDIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 GREENBRIAR DR
Mailing Address - Street 2:
Mailing Address - City:CAMPBELLSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42718-9616
Mailing Address - Country:US
Mailing Address - Phone:270-789-9999
Mailing Address - Fax:270-789-0247
Practice Address - Street 1:125 GREENBRIAR DR
Practice Address - Street 2:
Practice Address - City:CAMPBELLSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42718-9616
Practice Address - Country:US
Practice Address - Phone:270-789-9999
Practice Address - Fax:270-789-0247
Is Sole Proprietor?:No
Enumeration Date:2006-03-03
Last Update Date:2017-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010812902085R0001X
KY423742085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104495980Medicaid
KYC55045OtherCUMBERLAND HEALTHCARE
1366419814OtherTRICARE
KY7100060870Medicaid
000000664006OtherANTHEM
KY50028881OtherPASSPORT HEALTH PLAN/PASSPORT ADVANTAGE
000000664006OtherANTHEM
KY7100060870Medicaid
1366419814OtherTRICARE