=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871833301
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JEFF E HAGEN MD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/20/2013
-----------------------------------------------------
Last Update Date | 02/20/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 18810 HWY 290 E SUITE 100
-----------------------------------------------------
City | ELGIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78621-4240
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-285-3300
-----------------------------------------------------
Fax | 512-308-9649
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 301 HIGHWAY 71 W SUITE111
-----------------------------------------------------
City | BASTROP
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78602-4105
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-308-0318
-----------------------------------------------------
Fax | 512-308-9649
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JEFF E HAGEN
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 512-304-0318
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207VX0000X
-----------------------------------------------------
Taxonomy Name | Obstetrics Physician
-----------------------------------------------------
License Number | G3424
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------