Provider Demographics
NPI:1164484994
Name:HACKER, KENNETH ALLEN (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:ALLEN
Last Name:HACKER
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 1:6 JUNGERMANN CIRCLE
Mailing Address - Street 2:STE 205
Mailing Address - City:ST PETERS
Mailing Address - State:MO
Mailing Address - Zip Code:63376
Mailing Address - Country:US
Mailing Address - Phone:636-441-2122
Mailing Address - Fax:636-441-5290
Practice Address - Street 1:6 JUNGERMANN CIRCLE
Practice Address - Street 2:STE 205
Practice Address - City:ST PETERS
Practice Address - State:MO
Practice Address - Zip Code:63376
Practice Address - Country:US
Practice Address - Phone:636-441-2122
Practice Address - Fax:636-441-5290
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR5N50208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
29293OtherBLUE CHOICE
4337092OtherAETNA
088443OtherGREAT WEST
430910980007OtherPRUDENTIAL
017069OtherEXCLUSIVE CHOICE
020029159OtherRAILROAD MEDICARE
1053235OtherCARE PARTNER
1328V2907OtherGHP
1700152OtherUNITED HEALTHCARE
MO986C2OtherBLUE CROSS BLUE SHIELD
MO203711015Medicaid
G1257AOtherPRINCIPAL
209034OtherHEALTHLINK
11615OtherESSENCE
BLC27144001OtherBLUE CHOICE
SP14388OtherCIGNA
000487747642OtherMERCY
M6725OtherMEDICARE ARKANSAS
430910980007OtherPRUDENTIAL
MO000000411Medicare ID - Type Unspecified