Healthcare Provider Details

I. General information

NPI: 1396191359
Provider Name (Legal Business Name): MICHAEL HAGSTROM D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2016
Last Update Date: 08/03/2020
Certification Date: 08/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 KISH HOSPITAL DR
DEKALB IL
60115-9602
US

IV. Provider business mailing address

1 KISH HOSPITAL DR
DEKALB IL
60115-9602
US

V. Phone/Fax

Practice location:
  • Phone: 815-766-7334
  • Fax: 815-766-9768
Mailing address:
  • Phone: 815-766-7334
  • Fax: 815-766-9768

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number036148007
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: