Provider Demographics
NPI: | 1477562163 |
---|---|
Name: | HARDY, COURTNEY ALAN (MD) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | COURTNEY |
Middle Name: | ALAN |
Last Name: | HARDY |
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: | 225 E CHICAGO AVE |
Mailing Address - Street 2: | |
Mailing Address - City: | CHICAGO |
Mailing Address - State: | IL |
Mailing Address - Zip Code: | 60611-2991 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 312-227-4000 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 225 E CHICAGO AVE |
Practice Address - Street 2: | |
Practice Address - City: | CHICAGO |
Practice Address - State: | IL |
Practice Address - Zip Code: | 60611-2991 |
Practice Address - Country: | US |
Practice Address - Phone: | 312-227-4000 |
Practice Address - Fax: | |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-08-05 |
Last Update Date: | 2021-08-12 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
MO | 2017010204 | 207L00000X, 207LP3000X |
IL | 036107870 | 207LP3000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207LP3000X | Allopathic & Osteopathic Physicians | Anesthesiology | Pediatric Anesthesiology |
No | 207L00000X | Allopathic & Osteopathic Physicians | Anesthesiology |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
MO | 1477562163 | Medicaid | |
I33290 | Medicare UPIN | ||
MO | 269D927 | Medicare ID - Type Unspecified |