Provider Demographics
NPI:1568419901
Name:HACKETT, KEVIN C (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:C
Last Name:HACKETT
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 37813
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21297-7813
Mailing Address - Country:US
Mailing Address - Phone:301-733-0022
Mailing Address - Fax:301-733-3461
Practice Address - Street 1:11110 MEDICAL CAMPUS RD
Practice Address - Street 2:SUITE 228
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21742-6700
Practice Address - Country:US
Practice Address - Phone:301-733-0022
Practice Address - Fax:301-733-3461
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2016-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD47115208800000X
PAMD0550551208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD370801200Medicaid
MD370801200Medicaid
MDH530Medicare PIN