Provider Demographics
NPI:1073508602
Name:HARDISON, JEREMY LEONARD (MD)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:LEONARD
Last Name:HARDISON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:ME
Mailing Address - Zip Code:04011-2653
Mailing Address - Country:US
Mailing Address - Phone:434-947-3963
Mailing Address - Fax:434-947-5935
Practice Address - Street 1:121 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:ME
Practice Address - Zip Code:04011-2653
Practice Address - Country:US
Practice Address - Phone:207-661-2018
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2023-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2003-00611207R00000X
VA0101239901207RC0200X
MEMD26608207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
I08130Medicare UPIN