1043253602 NPI number — DR. SAM HAKKI HACKETTE MD

Table of content: DR. SAM HAKKI HACKETTE MD (NPI 1043253602)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043253602 NPI number — DR. SAM HAKKI HACKETTE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HAKKI HACKETTE
Provider First Name:
SAM
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HAKKI
Provider Other First Name:
SAM
Provider Other Middle Name:
Provider Other Name Prefix Text:
PROF.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1043253602
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/30/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 880
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STERLING HTS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48311-0880
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
27789 MOUND RD STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WARREN
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48092-2697
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
313-209-3353
Provider Business Practice Location Address Fax Number:
313-406-7255
Provider Enumeration Date:
06/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207XS0114X , with the licence number:  4301104354 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: MI7592002 . This is a "MEDICARE IDENTIFICATION NUMBER" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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