=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609929462
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TODD S HAGLE M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/18/2007
-----------------------------------------------------
Last Update Date | 02/09/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2210 DEAN ST STE K
-----------------------------------------------------
City | SAINT CHARLES
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60175-1059
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-223-1130
-----------------------------------------------------
Fax | 630-226-1134
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 329 REMINGTON BLVD STE 205
-----------------------------------------------------
City | BOLINGBROOK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60440-5817
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-226-1130
-----------------------------------------------------
Fax | 630-226-1134
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208VP0014X
-----------------------------------------------------
Taxonomy Name | Interventional Pain Medicine Physician
-----------------------------------------------------
License Number | 036111605
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207LP2900X
-----------------------------------------------------
Taxonomy Name | Pain Medicine (Anesthesiology) Physician
-----------------------------------------------------
License Number | 036111605
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------