Provider Demographics
NPI:1053303768
Name:HACK, JASON B (MD)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:B
Last Name:HACK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 751069
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1069
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2100 STANTONSBURG RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-2818
Practice Address - Country:US
Practice Address - Phone:252-744-4757
Practice Address - Fax:252-744-5014
Is Sole Proprietor?:No
Enumeration Date:2005-08-18
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD12717207P00000X
NC9900860207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI007060416OtherRI MEDICARE
RIJH72236Medicaid
MA2157683Medicaid
RI09/11/2008OtherNHPRI
NC891210AMedicaid
MA01/27/2009OtherTUFTS HEALTH PLAN
RI08/26/2008OtherBCBSRI
RI1053303768OtherNPI
NC1210AOtherBCBS NC
NC930080949OtherRAILROAD MEDICARE
RI007060416OtherRI MEDICARE
MA2157683Medicaid