Provider Demographics
NPI:1144228586
Name:HARDWICKE, MARYBETH (MD)
Entity Type:Individual
Prefix:DR
First Name:MARYBETH
Middle Name:
Last Name:HARDWICKE
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 673215
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48267-3215
Mailing Address - Country:US
Mailing Address - Phone:586-778-4080
Mailing Address - Fax:586-778-6055
Practice Address - Street 1:23411 JEFFERSON AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48080-1949
Practice Address - Country:US
Practice Address - Phone:586-778-4080
Practice Address - Fax:586-778-6055
Is Sole Proprietor?:No
Enumeration Date:2005-07-11
Last Update Date:2009-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIMH404922207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3384323Medicaid
MI0M9920003Medicare PIN
MIA79041Medicare UPIN