Provider Demographics
NPI:1144313107
Name:HACK, CHERYL HOPE (MD)
Entity type:Individual
Prefix:
First Name:CHERYL
Middle Name:HOPE
Last Name:HACK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25219 W ROYCOURT
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON WOODS
Mailing Address - State:MI
Mailing Address - Zip Code:48070-1741
Mailing Address - Country:US
Mailing Address - Phone:248-542-0660
Mailing Address - Fax:
Practice Address - Street 1:30301 WOODWARD AVE
Practice Address - Street 2:SUITE LL 165
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073-0979
Practice Address - Country:US
Practice Address - Phone:248-435-9240
Practice Address - Fax:248-435-4765
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010490512080P0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral Pediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
41049OtherOMNICARE ID
MI4171928Medicaid
11277774OtherCAQH PROVIDER ID
0004387354OtherAETNA ID
2199OtherCAPE ID
MI3506336142OtherBCBS PIN NUMBER
1003675OtherWELLNESS
1003675OtherWELLNESS