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NPI Code Detail

MEDICARE: DR. DERRICK JACK HAMILTON D.O.

MEDICARE: DR. DERRICK JACK HAMILTON D.O.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1207R00000XInternal Medicine Physician02998KY

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
11407818628OTHERKYMEDICIAID FQHC GROUP LEE
21962823393OTHERKYMEDICIAID FQHC GROUP WOLFE
3MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1376631283
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. DERRICK JACK HAMILTON D.O.
Provider Business Mailing Address
First Line : PO BOX 690
Second Line :
City : BEATTYVILLE
State : KY
Zip : 41311-0690
Country : US
Telephone Number : 606-464-0151
Fax Number : 606-464-0152
Provider Business Practice Location Address
First Line : 1484 LAKESIDE DRIVE
Second Line :
City : JACKSON
State : KY
Zip : 41339-6555
Country : US
Telephone Number : 606-666-9950
Fax Number : 606-666-9136
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/10/2006
Last Update Date : 03/13/2020

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