Provider Demographics
NPI:1669473815
Name:HARDISON, ROBERT DAMION (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:DAMION
Last Name:HARDISON
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 1:9405 LOMAX FOREST DR
Mailing Address - Street 2:
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20112-4448
Mailing Address - Country:US
Mailing Address - Phone:703-615-4141
Mailing Address - Fax:844-605-4187
Practice Address - Street 1:55 FOUNDATION DR
Practice Address - Street 2:
Practice Address - City:FLEMINGSBURG
Practice Address - State:KY
Practice Address - Zip Code:41041-9815
Practice Address - Country:US
Practice Address - Phone:606-849-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-09
Last Update Date:2021-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV25483207P00000X
VA0101251662207Q00000X, 207P00000X
KY46459207P00000X
TNMD36862207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3880452Medicaid
TN3880459Medicare PIN
TN3880452Medicaid
TN3880456Medicare ID - Type Unspecified