Provider Demographics
NPI:1215913520
Name:HACKMAN, VICKI LOU (MD)
Entity type:Individual
Prefix:
First Name:VICKI
Middle Name:LOU
Last Name:HACKMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 MAIN ST S
Mailing Address - Street 2:
Mailing Address - City:MC KEE
Mailing Address - State:KY
Mailing Address - Zip Code:40447-7089
Mailing Address - Country:US
Mailing Address - Phone:606-287-7104
Mailing Address - Fax:606-287-4409
Practice Address - Street 1:305 ESTILL ST
Practice Address - Street 2:
Practice Address - City:BEREA
Practice Address - State:KY
Practice Address - Zip Code:40403-1742
Practice Address - Country:US
Practice Address - Phone:859-985-1415
Practice Address - Fax:859-986-6752
Is Sole Proprietor?:No
Enumeration Date:2005-12-19
Last Update Date:2014-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY24411207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64244114Medicaid
KY0068122Medicare PIN
KYA82486Medicare UPIN
KY0737401Medicare PIN
KY0922018Medicare PIN