Provider Demographics
NPI:1073801148
Name:HARDIE, JOHN GEORGE (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:GEORGE
Last Name:HARDIE
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:PO BOX 3014
Mailing Address - Street 2:1215 DUFF AVENUE
Mailing Address - City:AMES
Mailing Address - State:IA
Mailing Address - Zip Code:50010-3014
Mailing Address - Country:US
Mailing Address - Phone:515-239-2411
Mailing Address - Fax:515-956-2714
Practice Address - Street 1:1111 DUFF AVENUE
Practice Address - Street 2:
Practice Address - City:AMES
Practice Address - State:IA
Practice Address - Zip Code:50010-3014
Practice Address - Country:US
Practice Address - Phone:515-239-2411
Practice Address - Fax:515-956-2714
Is Sole Proprietor?:No
Enumeration Date:2011-07-11
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN556432085R0001X
MN1063552085R0001X
IA435262085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAENROLLEDMedicaid
MNENROLLEDMedicaid
MNENROLLEDMedicaid