=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528039625
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANDRE HAGEVIK MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/28/2006
-----------------------------------------------------
Last Update Date | 03/25/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14520 W GRANITE VALLEY DR STE 120
-----------------------------------------------------
City | SUN CITY WEST
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85375-5855
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 866-974-2673
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 18444 N 25TH AVE STE 310
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85023-1266
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 866-974-2673
-----------------------------------------------------
Fax | 866-939-2673
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 29951
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 29951
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 2084N0400X
-----------------------------------------------------
Taxonomy Name | Neurology Physician
-----------------------------------------------------
License Number | 29951
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------