1164484994 NPI number — KENNETH ALLEN HACKER MD

Table of content: JULEE CAUDILL M.S., CCC-SLP (NPI 1285925487)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164484994 NPI number — KENNETH ALLEN HACKER MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HACKER
Provider First Name:
KENNETH
Provider Middle Name:
ALLEN
Provider Name Prefix Text:
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:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1164484994
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/06/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6 JUNGERMANN CIRCLE
Provider Second Line Business Mailing Address:
STE 205
Provider Business Mailing Address City Name:
ST PETERS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63376
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
636-441-2122
Provider Business Mailing Address Fax Number:
636-441-5290

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6 JUNGERMANN CIRCLE
Provider Second Line Business Practice Location Address:
STE 205
Provider Business Practice Location Address City Name:
ST PETERS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63376
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
636-441-2122
Provider Business Practice Location Address Fax Number:
636-441-5290
Provider Enumeration Date:
04/05/2006

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: 208600000X , with the licence number:  R5N50 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 29293 . This is a "BLUE CHOICE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 4337092 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 088443 . This is a "GREAT WEST" identifier . This identifiers is of the category "OTHER".
  • Identifier: 430910980007 . This is a "PRUDENTIAL" identifier . This identifiers is of the category "OTHER".
  • Identifier: 017069 . This is a "EXCLUSIVE CHOICE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 020029159 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1053235 . This is a "CARE PARTNER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1328V2907 . This is a "GHP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1700152 . This is a "UNITED HEALTHCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 986C2 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 203711015 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: G1257A . This is a "PRINCIPAL" identifier . This identifiers is of the category "OTHER".
  • Identifier: 209034 . This is a "HEALTHLINK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 11615 . This is a "ESSENCE" identifier . This identifiers is of the category "OTHER".
  • Identifier: BLC27144001 . This is a "BLUE CHOICE" identifier . This identifiers is of the category "OTHER".
  • Identifier: SP14388 . This is a "CIGNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000487747642 . This is a "MERCY" identifier . This identifiers is of the category "OTHER".
  • Identifier: M6725 . This is a "MEDICARE ARKANSAS" identifier . This identifiers is of the category "OTHER".




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