Provider Demographics
NPI:1417259805
Name:HAKE, MICHAEL JAMES (MD, PHD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JAMES
Last Name:HAKE
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 S NEW BALLAS RD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8221
Mailing Address - Country:US
Mailing Address - Phone:844-735-4710
Mailing Address - Fax:
Practice Address - Street 1:615 S NEW BALLAS RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8221
Practice Address - Country:US
Practice Address - Phone:844-735-4710
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-17
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ51841207R00000X
IN99102096A207R00000X
MO2024036759207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0101954Medicaid