Provider Demographics
NPI:1316168370
Name:TARDY, DANIEL DENNIS (PT)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:DENNIS
Last Name:TARDY
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 CHAPMAN STREET
Mailing Address - Street 2:
Mailing Address - City:BREWER
Mailing Address - State:ME
Mailing Address - Zip Code:04412
Mailing Address - Country:US
Mailing Address - Phone:207-478-6506
Mailing Address - Fax:207-989-9037
Practice Address - Street 1:40 CHAPMAN ST
Practice Address - Street 2:
Practice Address - City:BREWER
Practice Address - State:ME
Practice Address - Zip Code:04412-1810
Practice Address - Country:US
Practice Address - Phone:207-478-6506
Practice Address - Fax:978-225-2251
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2017-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPT1060225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME510550598OtherGREAT WEST
ME3662706OtherCIGNA
MEAA34198OtherHARVARD PILGRAM
MEP00286049OtherRR MEDICARE
ME048932OtherANTHEM
ME11317104OtherCAQH
ME1393159OtherAETNA
ME260240000Medicaid
ME260240000Medicaid