Provider Demographics
NPI:1992716732
Name:HAHN, KENNETH A (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:A
Last Name:HAHN
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 23998
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39225-3998
Mailing Address - Country:US
Mailing Address - Phone:662-725-2749
Mailing Address - Fax:662-725-2741
Practice Address - Street 1:1306 HOSPITAL ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MS
Practice Address - Zip Code:38703-3215
Practice Address - Country:US
Practice Address - Phone:662-334-9712
Practice Address - Fax:662-332-9703
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-10
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS14817207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00314972OtherRR MEDICARE
LA1597325Medicaid
MS00117699Medicaid
AR159492001Medicaid
E21588Medicare UPIN
MS060000809Medicare PIN