Provider Demographics
NPI:1215091863
Name:HARDISON, MICHAEL DAVID (DC)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:DAVID
Last Name:HARDISON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1624 E SELTICE WAY
Mailing Address - Street 2:
Mailing Address - City:POST FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83854-7022
Mailing Address - Country:US
Mailing Address - Phone:208-777-0128
Mailing Address - Fax:208-773-9600
Practice Address - Street 1:1624 E SELTICE WAY
Practice Address - Street 2:
Practice Address - City:POST FALLS
Practice Address - State:ID
Practice Address - Zip Code:83854-7022
Practice Address - Country:US
Practice Address - Phone:208-777-0128
Practice Address - Fax:208-773-9600
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2010-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA964111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807387600Medicaid
IDC2532OtherBLUE CROSS OF IDAHO
ID000010156505OtherREGENCE BLUE SHIELD
ID1675237Medicare ID - Type Unspecified
ID000010156505OtherREGENCE BLUE SHIELD