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General NPI Number Information
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NPI Number | 1942359401
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Entity Type | Organization
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Legal Business Name | MICHAEL T. HEGSTROM,MD, PLLC
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Dates
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Enumeration Date | 01/10/2007
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Last Update Date | 08/09/2011
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Provider Practice Location Address
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Address Line | 510 CHERRY STREET SUITE 206, BLGD. A
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City | BLUEFIELD
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State | WV
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Zip | 24701-3341
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Country | US
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Telephone | 304-327-1888
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Fax | 304-327-1889
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Provider Business Mailing Address
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Address Line | 510 CHERRY ST SUITE 206, BLDG A
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City | BLUEFIELD
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State | WV
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Zip | 24701-3338
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Country | US
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Telephone | 304-327-1888
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Fax | 304-327-1889
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Authorized Official
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Title or Position | PHYSICIAN
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Name | DR. MICHAEL TERRANCE HEGSTROM
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Credential | MD
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Telephone | 304-327-1888
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 21695
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License Number State | WV
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