Provider Demographics
NPI:1457340572
Name:HARDY, WILLIE (MD)
Entity Type:Individual
Prefix:
First Name:WILLIE
Middle Name:
Last Name:HARDY
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:PO BOX 1004
Mailing Address - Street 2:
Mailing Address - City:EDGEMONT
Mailing Address - State:PA
Mailing Address - Zip Code:19028-1004
Mailing Address - Country:US
Mailing Address - Phone:610-450-4559
Mailing Address - Fax:610-596-0255
Practice Address - Street 1:2219 ROBIN RD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19803-3036
Practice Address - Country:US
Practice Address - Phone:610-450-4559
Practice Address - Fax:610-596-0255
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD035425E207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA198854Medicare ID - Type Unspecified
C33356Medicare UPIN