=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104402767
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SAMUEL ELHARDT HAGER DO
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/23/2021
-----------------------------------------------------
Last Update Date | 02/03/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8401 S CHAMBERS RD # A-11
-----------------------------------------------------
City | ENGLEWOOD
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80112-3276
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 720-874-2420
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4686 N WILDFLOWERS WAY
-----------------------------------------------------
City | CASTLE ROCK
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80109-8400
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 701-202-6619
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 204D00000X
-----------------------------------------------------
Taxonomy Name | Neuromusculoskeletal Medicine & OMM Physician
-----------------------------------------------------
License Number | DR.0070052
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------