Provider Demographics
NPI:1255620662
Name:HOAG, MARK
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:HOAG
Suffix:
Gender:M
Credentials:
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 550
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:KS
Mailing Address - Zip Code:66770-0550
Mailing Address - Country:US
Mailing Address - Phone:620-848-2300
Mailing Address - Fax:
Practice Address - Street 1:6610 SE QUAKERVALE RD
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:KS
Practice Address - Zip Code:66770-4185
Practice Address - Country:US
Practice Address - Phone:620-848-2300
Practice Address - Fax:620-848-2301
Is Sole Proprietor?:No
Enumeration Date:2011-04-06
Last Update Date:2011-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS1205970126Medicaid