MEDICARE: DR. GREGORY B. HAGEDORN, OD

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	332H00000X	Eyewear Supplier	1016DT	KY

General Provider Information

NPI Number	:	1205013547
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DR. GREGORY B. HAGEDORN, OD

Provider Business Mailing Address
First Line	:	PO BOX 577
Second Line	:
City	:	HENDERSON
State	:	KY
Zip	:	42419-0577
Country	:	US
Telephone Number	:	270-826-1500
Fax Number	:	270-827-0757

Provider Business Practice Location Address
First Line	:	1413 N ELM ST
Second Line	:	SUITE 102
City	:	HENDERSON
State	:	KY
Zip	:	42420-2768
Country	:	US
Telephone Number	:	270-826-1500
Fax Number	:	270-827-0757

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MRS. JAN M RUTHERFORD
Credential	:
Telephone Number	:	270-826-1500

Provider Enumeration Date	:	01/29/2008
Last Update Date	:	04/27/2009

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