MEDICARE: NATHAN B HAGEN 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	207Q00000X	Family Medicine Physician	3113	ND
2	208D00000X	General Practice Physician	3113	ND

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	33401	OTHER		REFERRING

General Provider Information

NPI Number	:	1518049931
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NATHAN B HAGEN MD

Provider Business Mailing Address
First Line	:	PO BOX 290
Second Line	:	115 SO ST
City	:	MICHIGAN
State	:	ND
Zip	:	58259-0290
Country	:	US
Telephone Number	:	701-259-2119
Fax Number	:	701-259-2319

Provider Business Practice Location Address
First Line	:	115 SOUTH ST
Second Line	:	MICHIGAN COMMUNITY MEDICAL CLINIC
City	:	MICHIGAN
State	:	ND
Zip	:	58259-0290
Country	:	US
Telephone Number	:	701-259-2119
Fax Number	:	701-259-2319

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

Provider Enumeration Date	:	10/19/2006
Last Update Date	:	10/29/2007

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