Provider Demographics
NPI:1184688749
Name:HACKETT, MICHAEL D (CRNA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:D
Last Name:HACKETT
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2288 GUNBARREL RD STE 111 PMB 237
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421-2670
Mailing Address - Country:US
Mailing Address - Phone:412-337-0283
Mailing Address - Fax:
Practice Address - Street 1:800 ROSE ST
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40536-7001
Practice Address - Country:US
Practice Address - Phone:859-323-5956
Practice Address - Fax:859-323-1080
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-12
Last Update Date:2021-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN356726L367500000X
FL3291412367500000X
KY1105174163W00000X
OH08204367500000X
KY3004468367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000542747OtherANTHEM
PA70965OtherCOUNCIL OF RECERT OF NA #
OH2484815Medicaid
9487921OtherPHCS
KY7401086900Medicaid
IN200519280Medicaid
$$$$$$$$$ 611077369OtherHEALTHNET
000000542747OtherANTHEM
$$$$$$$$$ 611077369OtherHEALTHNET
0918141Medicare PIN
P00448878Medicare PIN