Healthcare Provider Details

I. General information

NPI: 1437126596
Provider Name (Legal Business Name): CULLEN B HEGARTY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2006
Last Update Date: 09/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

640 JACKSON ST MC 11102F
ST PAUL MN
55101-2502
US

IV. Provider business mailing address

8100 34TH AVE S MC21110Q
BLOOMINGTON MN
55425-1672
US

V. Phone/Fax

Practice location:
  • Phone: 651-254-3456
  • Fax: 651-254-5216
Mailing address:
  • Phone: 952-883-7172
  • Fax: 952-883-5395

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number43032
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number41633
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: