Basic Information
| Provider Information | |||||||||
| NPI: | 1114071206 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HACKETT MEDICAL LTD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8300 TYLER BLVD | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | MENTOR | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440604217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4402051529 | ||||||||
| FaxNumber: | 4402050840 | ||||||||
| Practice Location | |||||||||
| Address1: | 8300 TYLER BLVD | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | MENTOR | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440604217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4402051529 | ||||||||
| FaxNumber: | 4402050840 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2007 | ||||||||
| LastUpdateDate: | 08/03/2017 | ||||||||
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| AuthorizedOfficialLastName: | HACKETT | ||||||||
| AuthorizedOfficialFirstName: | MARTHA | ||||||||
| AuthorizedOfficialMiddleName: | NOFZIGER | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER HACKETT MEDICAL LTD. | ||||||||
| AuthorizedOfficialTelephone: | 4402051529 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 35043939 | OH | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2178905 | 05 | OH | MEDICAID |