Provider Demographics
NPI:1881640035
Name:HARDEE FAMILY MEDICINE PA
Entity Type:Organization
Organization Name:HARDEE FAMILY MEDICINE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:HARDEE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:704-658-9779
Mailing Address - Street 1:444 WILLIAMSON RD STE E
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117-9248
Mailing Address - Country:US
Mailing Address - Phone:704-658-9779
Mailing Address - Fax:704-658-9773
Practice Address - Street 1:444 WILLIAMSON RD SUITE E
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117
Practice Address - Country:US
Practice Address - Phone:704-658-9779
Practice Address - Fax:704-658-9773
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-26
Last Update Date:2015-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200000816207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC34D1027431OtherCLIA MEDICARE/MEDICAID
NC7902629Medicaid
NC34D1027431OtherCLIA MEDICARE/MEDICAID
NC2343880Medicare ID - Type Unspecified