Provider Demographics
NPI:1780661835
Name:HAY, JACK EVERETT (DO)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:EVERETT
Last Name:HAY
Suffix:
Gender:
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:530 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:OBERLIN
Mailing Address - State:OH
Mailing Address - Zip Code:44074-1743
Mailing Address - Country:US
Mailing Address - Phone:440-707-6247
Mailing Address - Fax:888-450-1239
Practice Address - Street 1:530 S MAIN ST
Practice Address - Street 2:
Practice Address - City:OBERLIN
Practice Address - State:OH
Practice Address - Zip Code:44074-1743
Practice Address - Country:US
Practice Address - Phone:440-707-6247
Practice Address - Fax:888-450-1239
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-29
Last Update Date:2025-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH340084192083A0300X, 208D00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No2083A0300XAllopathic & Osteopathic PhysiciansPreventive MedicineAddiction Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2612908Medicaid
OHP00779560Medicare PIN
OH2612908Medicaid