Basic Information
| Provider Information | |||||||||
| NPI: | 1033215017 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HAMMAN | ||||||||
| FirstName: | JACK | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 CLINIC DR | ||||||||
| Address2: | |||||||||
| City: | MADISONVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 424311661 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 800 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | MADISONVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 424311658 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2703263800 | ||||||||
| FaxNumber: | 2703263805 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2006 | ||||||||
| LastUpdateDate: | 12/04/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 14714 | KY | N | Allopathic & Osteopathic Physicians | Surgery | 2086S0129X | 14714 | KY | N | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery | 208G00000X | 14714 | KY | Y | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
ID Information
| ID | Type | State | Issuer | Description | 000000044325 | 01 | BCBS PROVIDER NUMBER | OTHER | 14714 | 01 | KY | LICENSE | OTHER | 64147143 | 05 | KY | MEDICAID |