Provider Demographics
NPI:1033612528
Name:HARDY, BERNARD LAMAR II (MD)
Entity type:Individual
Prefix:
First Name:BERNARD
Middle Name:LAMAR
Last Name:HARDY
Suffix:II
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 1:24811 RENSSELAER ST
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48237-1773
Mailing Address - Country:US
Mailing Address - Phone:424-251-1393
Mailing Address - Fax:
Practice Address - Street 1:2651 E DISCOVERY PKWY
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47408-9059
Practice Address - Country:US
Practice Address - Phone:812-676-4102
Practice Address - Fax:812-676-4106
Is Sole Proprietor?:No
Enumeration Date:2018-03-12
Last Update Date:2024-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5315226945390200000X
MI4351048740390200000X
IN01094213A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300093374Medicaid
IN090541002OtherMEDICARE PTAN