Provider Demographics
NPI:1598921892
Name:HARDIN, BRENT MONTAGUE
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:MONTAGUE
Last Name:HARDIN
Suffix:
Gender:M
Credentials:
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 1013
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MS
Mailing Address - Zip Code:38655-1013
Mailing Address - Country:US
Mailing Address - Phone:662-234-1448
Mailing Address - Fax:662-234-1490
Practice Address - Street 1:1201 MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655-5327
Practice Address - Country:US
Practice Address - Phone:662-234-1448
Practice Address - Fax:662-234-1490
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-06
Last Update Date:2013-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN390200000X
MS22422208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program