Provider Demographics
NPI:1437148582
Name:HARDIGAN, KENNETH RUSSELL (MD)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:RUSSELL
Last Name:HARDIGAN
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 1:100 LANTANA RD STE 202A
Mailing Address - Street 2:
Mailing Address - City:CROSSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38555-1915
Mailing Address - Country:US
Mailing Address - Phone:931-484-5141
Mailing Address - Fax:
Practice Address - Street 1:100 LANTANA RD STE 202A
Practice Address - Street 2:
Practice Address - City:CROSSVILLE
Practice Address - State:TN
Practice Address - Zip Code:38555-1915
Practice Address - Country:US
Practice Address - Phone:931-484-5141
Practice Address - Fax:865-374-2074
Is Sole Proprietor?:No
Enumeration Date:2005-10-20
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA039120207RC0000X
TN65348207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ074573Medicaid
GA000852596AMedicaid
GA00627327GMedicaid
SCSC5332E470Medicare PIN
GA00627327GMedicaid