Healthcare Provider Details

I. General information

NPI: 1558591891
Provider Name (Legal Business Name): BRENT PHILIP HAZEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/21/2009
Last Update Date: 04/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4451 BAYOU BLVD
PENSACOLA FL
32503-2601
US

IV. Provider business mailing address

PO BOX 2699 ATTN: SHMG/HPE
PENSACOLA FL
32513-2699
US

V. Phone/Fax

Practice location:
  • Phone: 850-416-7619
  • Fax: 850-416-7753
Mailing address:
  • Phone: 850-416-7619
  • Fax: 850-416-7753

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMT196193
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number57.017460
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME114426
License Number StateFL
# 4
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberME114426
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: