Basic Information
| Provider Information | |||||||||
| NPI: | 1184693749 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HARDESTY | ||||||||
| FirstName: | GLENN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | P O BOX 960160 | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731960001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8774854474 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 800 W RANDOL MILL RD | ||||||||
| Address2: | |||||||||
| City: | ARLINGTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760122504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8175486202 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2006 | ||||||||
| LastUpdateDate: | 10/15/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | K8201 | TX | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 88778Z | 01 | TX | BCBS THRU AEMA | OTHER | 029651902 | 05 | TX | MEDICAID | 8BT321 | 01 | TX | BCBS THRU SAEMA | OTHER | 930124542 | 01 | TX | RAILROAD THRU AEMA | OTHER | P01207143 | 01 | TX | RAILROAD MCARE | OTHER | 029651903 | 05 | TX | MEDICAID |