Provider Demographics
NPI:1508869736
Name:HARDEBECK, CHARLES J (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:J
Last Name:HARDEBECK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:700 ACKERMAN RD
Mailing Address - Street 2:SUITE 385
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43202-1559
Mailing Address - Country:US
Mailing Address - Phone:614-947-3700
Mailing Address - Fax:614-947-3771
Practice Address - Street 1:473 W 12TH AVE
Practice Address - Street 2:HLRI, 2ND FLOOR
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43210-1252
Practice Address - Country:US
Practice Address - Phone:614-947-3700
Practice Address - Fax:614-947-3771
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2010-09-17
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
KY21052207RC0000X
OH35047571207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64210529Medicaid
OH0545459Medicaid
OH0545459Medicaid
OHHA4179001Medicare PIN