MEDICARE: MARK HAGERTY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	209014451	IL

General Provider Information

NPI Number	:	1518410794
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARK HAGERTY

Provider Business Mailing Address
First Line	:	2901 W TOUHY AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60645-2937
Country	:	US
Telephone Number	:	773-973-7350
Fax Number	:	773-973-0506

Provider Business Practice Location Address
First Line	:	2901 W TOUHY AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60645-2937
Country	:	US
Telephone Number	:	773-973-7350
Fax Number	:	773-973-0506

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/25/2016
Last Update Date	:	07/25/2016

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