Healthcare Provider Details

I. General information

NPI: 1568463057
Provider Name (Legal Business Name): REBECCA HAGERTY DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2005
Last Update Date: 01/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 SIXTH ST STE 400
TRAVERSE CITY MI
49684-2369
US

IV. Provider business mailing address

1200 SIXTH ST STE 400
TRAVERSE CITY MI
49684-2369
US

V. Phone/Fax

Practice location:
  • Phone: 231-392-0650
  • Fax: 231-392-0665
Mailing address:
  • Phone: 231-392-0650
  • Fax: 231-392-0665

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberRV013390
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: