Provider Demographics
NPI:1134125024
Name:HACKL, PAMELA J (DO)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:J
Last Name:HACKL
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7443 JACKMAN RD
Mailing Address - Street 2:
Mailing Address - City:TEMPERANCE
Mailing Address - State:MI
Mailing Address - Zip Code:48182-9223
Mailing Address - Country:US
Mailing Address - Phone:734-850-0100
Mailing Address - Fax:888-491-3525
Practice Address - Street 1:7443 JACKMAN RD
Practice Address - Street 2:
Practice Address - City:TEMPERANCE
Practice Address - State:MI
Practice Address - Zip Code:48182-9223
Practice Address - Country:US
Practice Address - Phone:734-850-0100
Practice Address - Fax:734-850-0112
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-24
Last Update Date:2022-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101011928207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHHA0889071Medicaid
MI0M97830Medicare ID - Type Unspecified
MI18010001Medicare PIN
OHHA0889071Medicaid