Provider Demographics
NPI:1528173325
Name:HACKETT, RAYMOND ALLEN (MD)
Entity type:Individual
Prefix:DR
First Name:RAYMOND
Middle Name:ALLEN
Last Name:HACKETT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1325
Mailing Address - Street 2:
Mailing Address - City:CORBIN
Mailing Address - State:KY
Mailing Address - Zip Code:40702-1325
Mailing Address - Country:US
Mailing Address - Phone:606-526-8131
Mailing Address - Fax:606-528-8661
Practice Address - Street 1:140 BRYAN BLVD
Practice Address - Street 2:
Practice Address - City:CORBIN
Practice Address - State:KY
Practice Address - Zip Code:40701-2775
Practice Address - Country:US
Practice Address - Phone:606-528-1172
Practice Address - Fax:606-528-7169
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-20
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN30657208800000X
KY45767208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
06173HAOtherBLUE CROSS
MN084583300Medicaid
1900010OtherMEDICA PRIMARY
961240267002OtherPREFERRED ONE
KYP01427472OtherRR MEDICARE
1912600OtherMEDICA
A06082OtherWAUSAU
HP13441OtherHEALTHPARTNERS
101379C118OtherUCARE
MN340004898OtherRAILROAD MEDICARE
WI34603700Medicaid
KY7100228250Medicaid
MN340004898OtherRAILROAD MEDICARE
101379C118OtherUCARE
KYP01427472OtherRR MEDICARE
1900010OtherMEDICA PRIMARY
MNA06082Medicare UPIN