Provider Demographics
NPI:1275581076
Name:HACKNEY, MARK A (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:A
Last Name:HACKNEY
Suffix:
Gender:M
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:PO BOX 890707
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28289-0707
Mailing Address - Country:US
Mailing Address - Phone:866-338-6463
Mailing Address - Fax:614-717-9840
Practice Address - Street 1:700 VILLAGE DR
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:WV
Practice Address - Zip Code:26554-7985
Practice Address - Country:US
Practice Address - Phone:304-366-2600
Practice Address - Fax:304-366-2080
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2007-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV209632085R0202X
KYTP1992085R0202X
OH35.0872952085R0202X
IN01061747A2085R0202X
IL361146762085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810001885Medicaid
000000163377OtherUNISON FORMERLY 3 RIVERS
WV1065856OtherWV WORKERS COMP
OH000000384890OtherBCBS
OHP00285685Medicare ID - Type UnspecifiedRAILROAD
WV4146792Medicare ID - Type Unspecified
WV3810001885Medicaid
OH000000384890OtherBCBS
I21315Medicare UPIN
WVP00178087Medicare ID - Type UnspecifiedRAILROAD