Healthcare Provider Details

I. General information

NPI: 1851977490
Provider Name (Legal Business Name): MATHEW ADAM HAGEN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2021
Last Update Date: 08/21/2024
Certification Date: 08/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 OAKFIELD DR
BRANDON FL
33511-5779
US

IV. Provider business mailing address

4609 W HAWTHORNE RD
TAMPA FL
33611-3120
US

V. Phone/Fax

Practice location:
  • Phone: 813-681-5551
  • Fax: 813-916-2944
Mailing address:
  • Phone: 256-763-1413
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License NumberOS21075
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: