Healthcare Provider Details

I. General information

NPI: 1245203306
Provider Name (Legal Business Name): GREGORY N HAGAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2006
Last Update Date: 11/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 WINDSOR ST WINDSOR STREET HEALTH CENTER
CAMBRIDGE MA
02139-3647
US

IV. Provider business mailing address

1493 CAMBRIDGE ST
CAMBRIDGE MA
02139-1047
US

V. Phone/Fax

Practice location:
  • Phone: 617-665-3600
  • Fax: 617-665-3603
Mailing address:
  • Phone: 617-665-1616
  • Fax: 617-665-1976

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number70814
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: