Provider Demographics
NPI:1104932466
Name:ACKERMANN, MARK A (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:ACKERMANN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 LORETTO RD STE 500A
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:KY
Mailing Address - Zip Code:40033-1308
Mailing Address - Country:US
Mailing Address - Phone:270-699-2229
Mailing Address - Fax:270-699-9740
Practice Address - Street 1:330 LORETTO RD STE 500A
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:KY
Practice Address - Zip Code:40033-1308
Practice Address - Country:US
Practice Address - Phone:270-699-2229
Practice Address - Fax:270-699-9740
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY32261207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64319973Medicaid
KY0572502Medicare ID - Type Unspecified
KY64319973Medicaid