Basic Information
| Provider Information | |||||||||
| NPI: | 1629061932 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HARDMAN | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | WINTERBOTHAM | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2121 PARK ST | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322043811 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043876200 | ||||||||
| FaxNumber: | 9043870261 | ||||||||
| Practice Location | |||||||||
| Address1: | 2121 PARK ST | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322043811 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043876200 | ||||||||
| FaxNumber: | 9043870261 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2005 | ||||||||
| LastUpdateDate: | 02/13/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080A0000X | ME 76418 | FL | Y | Allopathic & Osteopathic Physicians | Pediatrics | Adolescent Medicine | 208000000X | ME76418 | FL | N | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 259018200 | 05 | FL | MEDICAID |