Provider Demographics
NPI:1619073681
Name:HACK, MICHAEL L (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:L
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 1:200 CLINIC DR
Mailing Address - Street 2:
Mailing Address - City:MADISONVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42431-1661
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:225 INDUSTRIAL PARK RD
Practice Address - Street 2:
Practice Address - City:DAWSON SPRINGS
Practice Address - State:KY
Practice Address - Zip Code:42408-2423
Practice Address - Country:US
Practice Address - Phone:270-797-3521
Practice Address - Fax:270-797-3292
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY37313207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000200932OtherBCBS PROVIDER NUMBER
KY64047905Medicaid
KY37313OtherLICENSE
0374689Medicare PIN
KY64047905Medicaid
000000200932OtherBCBS PROVIDER NUMBER
0396819Medicare PIN
0375182Medicare PIN
0375286Medicare PIN
0661940Medicare PIN
KY37313OtherLICENSE
H40179Medicare UPIN
0600258Medicare PIN
KY080172927Medicare PIN