Basic Information
| Provider Information | |||||||||
| NPI: | 1366419814 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HARDIN | ||||||||
| FirstName: | PETER | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 125 GREENBRIAR DR | ||||||||
| Address2: | |||||||||
| City: | CAMPBELLSVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 427189616 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707899999 | ||||||||
| FaxNumber: | 2707890247 | ||||||||
| Practice Location | |||||||||
| Address1: | 125 GREENBRIAR DR | ||||||||
| Address2: | |||||||||
| City: | CAMPBELLSVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 427189616 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707899999 | ||||||||
| FaxNumber: | 2707890247 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/03/2006 | ||||||||
| LastUpdateDate: | 02/01/2017 | ||||||||
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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 | 2085R0001X | 4301081290 | MI | N | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology | 2085R0001X | 42374 | KY | Y | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
| ID | Type | State | Issuer | Description | 104495980 | 05 | MI | MEDICAID | C55045 | 01 | KY | CUMBERLAND HEALTHCARE | OTHER | 1366419814 | 01 | TRICARE | OTHER | 7100060870 | 05 | KY | MEDICAID | 000000664006 | 01 | ANTHEM | OTHER | 50028881 | 01 | KY | PASSPORT HEALTH PLAN/PASSPORT ADVANTAGE | OTHER |