Provider Demographics
NPI:1073508602
Name:HARDISON, JEREMY LEONARD (MD)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:LEONARD
Last Name:HARDISON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:121 MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:ME
Mailing Address - Zip Code:04011-2653
Mailing Address - Country:US
Mailing Address - Phone:434-947-3963
Mailing Address - Fax:434-947-5935
Practice Address - Street 1:234 CROOKED CREEK PKWY
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27713-8505
Practice Address - Country:US
Practice Address - Phone:919-385-3000
Practice Address - Fax:919-576-8822
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2025-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2003-00611207R00000X
MEMD26608207R00000X
VA0101239901207RC0200X
NC200300611207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
I08130Medicare UPIN