Provider Demographics
NPI:1184697021
Name:HACKENBERG-BAUER, PETRA H (MD)
Entity type:Individual
Prefix:
First Name:PETRA
Middle Name:H
Last Name:HACKENBERG-BAUER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7400 JAGER CT
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45230-4344
Mailing Address - Country:US
Mailing Address - Phone:513-232-8100
Mailing Address - Fax:513-232-3875
Practice Address - Street 1:7400 JAGER CT
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45230-4344
Practice Address - Country:US
Practice Address - Phone:513-232-8100
Practice Address - Fax:513-232-3875
Is Sole Proprietor?:No
Enumeration Date:2006-02-10
Last Update Date:2011-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35066134208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0637479OtherAETNA
OH000000007724OtherANTHEM BC/BS
OH1220465OtherUNITED HEALTHCARE
OH6613401OtherHUMANA
OH0964667Medicaid
OH6613401OtherHUMANA