Provider Demographics
NPI:1780661835
Name:HAY, JACK EVERETT (DO)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:EVERETT
Last Name:HAY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2791 LORETO DR
Mailing Address - Street 2:
Mailing Address - City:WILLOUGHBY HILLS
Mailing Address - State:OH
Mailing Address - Zip Code:44094-9453
Mailing Address - Country:US
Mailing Address - Phone:440-487-5334
Mailing Address - Fax:800-503-9484
Practice Address - Street 1:36000 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:WILLOUGHBY
Practice Address - State:OH
Practice Address - Zip Code:44094-4625
Practice Address - Country:US
Practice Address - Phone:440-953-9600
Practice Address - Fax:800-503-9484
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-29
Last Update Date:2010-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34008419207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2612908Medicaid
OHP00779560Medicare PIN
OH2612908Medicaid