Provider Demographics
NPI:1750329629
Name:HARDY, SCOTT RUSSELL (DO)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:RUSSELL
Last Name:HARDY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37 S 2ND E
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-1906
Mailing Address - Country:US
Mailing Address - Phone:208-356-0234
Mailing Address - Fax:208-656-8444
Practice Address - Street 1:37 S 2ND E
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-1906
Practice Address - Country:US
Practice Address - Phone:208-356-0234
Practice Address - Fax:208-656-8444
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2021-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDO-306207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1689769465Medicaid
G42439Medicare UPIN
ID1302673Medicare PIN