Provider Demographics
NPI:1306931001
Name:HACKETT, TRACI GILES (MD)
Entity type:Individual
Prefix:DR
First Name:TRACI
Middle Name:GILES
Last Name:HACKETT
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 1:5932 LAKE CYRUS DR
Mailing Address - Street 2:
Mailing Address - City:HOOVER
Mailing Address - State:AL
Mailing Address - Zip Code:35244-4162
Mailing Address - Country:US
Mailing Address - Phone:334-300-7480
Mailing Address - Fax:
Practice Address - Street 1:1836 W MAIN ST
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36301-1320
Practice Address - Country:US
Practice Address - Phone:334-699-8585
Practice Address - Fax:334-699-8587
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2014-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL23561207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51530696OtherBCBS
AL529925720Medicaid
H24105Medicare UPIN
51530696Medicare ID - Type Unspecified