Healthcare Provider Details

I. General information

NPI: 1801423660
Provider Name (Legal Business Name): MICHAEL HEGSTROM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: MIKAEL HAGGSTROM MD

II. Dates (important events)

Enumeration Date: 03/23/2020
Last Update Date: 03/27/2026
Certification Date: 03/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 DELAWARE ST SE
MINNEAPOLIS MN
55455-0341
US

IV. Provider business mailing address

7222 KIMBERLY LN N
MAPLE GROVE MN
55311-4563
US

V. Phone/Fax

Practice location:
  • Phone: 612-626-0622
  • Fax: 612-625-4411
Mailing address:
  • Phone: 612-360-3910
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number14024660-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: