Healthcare Provider Details

I. General information

NPI: 1558303511
Provider Name (Legal Business Name): ROBERT R HAGAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 02/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

621 S NEW BALLAS RD SUITE 611A
SAINT LOUIS MO
63141-8232
US

IV. Provider business mailing address

1836 LACKLAND HILL PKWY
SAINT LOUIS MO
63146-3572
US

V. Phone/Fax

Practice location:
  • Phone: 314-251-6587
  • Fax: 314-251-4775
Mailing address:
  • Phone: 314-989-0300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number2002014082
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: