Provider Demographics
NPI:1750346482
Name:HACK, ALLEN DEAN (MD)
Entity type:Individual
Prefix:
First Name:ALLEN
Middle Name:DEAN
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 1:6801 DIXIE HWY
Mailing Address - Street 2:SUITE 130
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40258-3913
Mailing Address - Country:US
Mailing Address - Phone:502-367-3360
Mailing Address - Fax:502-367-3365
Practice Address - Street 1:1850 BLUEGRASS AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40215-1161
Practice Address - Country:US
Practice Address - Phone:502-367-3360
Practice Address - Fax:502-367-3365
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2016-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY25887207R00000X, 208000000X
ORMD171953208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64258890Medicaid
KY000000633080OtherANTHEM
IN200961230AMedicaid
KY000000633080OtherANTHEM
E46547Medicare UPIN
KY00546231Medicare Oscar/Certification
KY01104002Medicare PIN