Basic Information
| Provider Information | |||||||||
| NPI: | 1053303768 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HACK | ||||||||
| FirstName: | JASON | ||||||||
| MiddleName: | B | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 751069 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282751069 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2100 STANTONSBURG RD | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 278342818 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2527444757 | ||||||||
| FaxNumber: | 2527445014 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2005 | ||||||||
| LastUpdateDate: | 12/01/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | MD12717 | RI | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 9900860 | NC | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 891210A | 05 | NC | MEDICAID | 007060416 | 01 | RI | RI MEDICARE | OTHER | 2157683 | 05 | MA | MEDICAID | JH72236 | 05 | RI | MEDICAID | 08/26/2008 | 01 | RI | BCBSRI | OTHER | 09/11/2008 | 01 | RI | NHPRI | OTHER | 01/27/2009 | 01 | MA | TUFTS HEALTH PLAN | OTHER | 1053303768 | 01 | RI | NPI | OTHER | 930080949 | 01 | NC | RAILROAD MEDICARE | OTHER | 1210A | 01 | NC | BCBS NC | OTHER |