Healthcare Provider Details

I. General information

NPI: 1245249192
Provider Name (Legal Business Name): RONALD G HAGEMAN AUD CCCA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/07/2006
Last Update Date: 05/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2505 E PARIS AVE SE STE 170
GRAND RAPIDS MI
49546-2459
US

IV. Provider business mailing address

2505 E PARIS AVE SE STE 170
GRAND RAPIDS MI
49546-2459
US

V. Phone/Fax

Practice location:
  • Phone: 616-285-3733
  • Fax: 616-285-5960
Mailing address:
  • Phone: 616-285-3733
  • Fax: 616-285-5960

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License Number1601000046
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: