1164484994 NPI number — KENNETH ALLEN HACKER MD

Table of content: KENNETH ALLEN HACKER MD (NPI 1164484994)

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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