MEDICARE: THOMAS A. HACKENBERG MD

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
1	207RI0200X	Infectious Disease Physician	35232	CO

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	440001691	OTHER	CO	RAIL ROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	0970329	OTHER	CO	AETNA
4	41366	OTHER	CO	BLUE CROSS

General Provider Information

NPI Number	:	1659371524
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THOMAS A. HACKENBERG MD

Provider Business Mailing Address
First Line	:	3230 E WOODMEN RD
Second Line	:	SUITE 210
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80920
Country	:	US
Telephone Number	:	719-578-5176
Fax Number	:	719-578-5188

Provider Business Practice Location Address
First Line	:	3230 E WOODMEN RD
Second Line	:	SUITE 210
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80920
Country	:	US
Telephone Number	:	719-578-5176
Fax Number	:	719-578-5188

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/21/2005
Last Update Date	:	06/11/2013

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