Basic Information
| Provider Information | |||||||||
| NPI: | 1184688749 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HACKETT | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2288 GUNBARREL RD STE 111 PMB 237 | ||||||||
| Address2: | |||||||||
| City: | CHATTANOOGA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 374212670 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4123370283 | ||||||||
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| Practice Location | |||||||||
| Address1: | 800 ROSE ST | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405367001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593235956 | ||||||||
| FaxNumber: | 8593231080 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2006 | ||||||||
| LastUpdateDate: | 07/07/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | RN356726L | PA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | 3291412 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 163W00000X | 1105174 | KY | N | Nursing Service Providers | Registered Nurse | 367500000X | 08204 | OH | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | 3004468 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 000000542747 | 01 | ANTHEM | OTHER | 70965 | 01 | PA | COUNCIL OF RECERT OF NA # | OTHER | 2484815 | 05 | OH | MEDICAID | 9487921 | 01 | PHCS | OTHER | 7401086900 | 05 | KY | MEDICAID | 200519280 | 05 | IN | MEDICAID |