Provider Demographics
NPI:1609184472
Name:KIM A HARDEY A PROFESSIONAL MEDICAL CORPORATION
Entity Type:Organization
Organization Name:KIM A HARDEY A PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KIM
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:HARDEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:337-261-5433
Mailing Address - Street 1:1211 COOLIDGE BLVD
Mailing Address - Street 2:SUITE 403
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70503-2636
Mailing Address - Country:US
Mailing Address - Phone:337-261-5433
Mailing Address - Fax:337-269-9652
Practice Address - Street 1:1211 COOLIDGE BLVD
Practice Address - Street 2:SUITE 403
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70503-2636
Practice Address - Country:US
Practice Address - Phone:337-261-5433
Practice Address - Fax:337-269-9652
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-15
Last Update Date:2010-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA016206174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1345911Medicaid
LA1345911Medicaid
LA5U078Medicare PIN