Healthcare Provider Details

I. General information

NPI: 1689671331
Provider Name (Legal Business Name): EDWARD PAUL HAGEN D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2005
Last Update Date: 06/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

265 GRIFFIN ST E
AMERY WI
54001-1439
US

IV. Provider business mailing address

265 GRIFFIN ST E
AMERY WI
54001-1439
US

V. Phone/Fax

Practice location:
  • Phone: 715-268-8000
  • Fax: 715-268-0311
Mailing address:
  • Phone: 715-268-8000
  • Fax: 715-268-0311

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number02734
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number3890
License Number StateSD
# 3
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number54529
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: