Basic Information
| Provider Information | |||||||||
| NPI: | 1336252527 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HARDISKY | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | JOSEPH | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1812 MARSH RD | ||||||||
| Address2: | STORE 505 | ||||||||
| City: | WILMINGTON | ||||||||
| State: | DE | ||||||||
| PostalCode: | 198104581 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3027930432 | ||||||||
| FaxNumber: | 3027930400 | ||||||||
| Practice Location | |||||||||
| Address1: | 3465 BOX HILL CORP CTR DR | ||||||||
| Address2: | STE G | ||||||||
| City: | ABINGDON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210091261 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4105634806 | ||||||||
| FaxNumber: | 4105695474 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2006 | ||||||||
| LastUpdateDate: | 08/21/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 19927 | MD | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 014156 | 01 | JOHNS HOPKINS | OTHER | 5070-0057 | 01 | CARE FIRST | OTHER | 3316661000 | 01 | AMERIHEALTH IBC | OTHER | 88760514 | 01 | CARE FIRST | OTHER |