Provider Demographics
NPI:1063646131
Name:HAGELSTEIN, CRISTIN SAMANTHA (MD)
Entity Type:Individual
Prefix:
First Name:CRISTIN
Middle Name:SAMANTHA
Last Name:HAGELSTEIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 191
Mailing Address - Street 2:PROVIDER ENROLLMENT DEPARTMENT
Mailing Address - City:ROCKLAND
Mailing Address - State:DE
Mailing Address - Zip Code:19732-0191
Mailing Address - Country:US
Mailing Address - Phone:302-651-6212
Mailing Address - Fax:302-651-4945
Practice Address - Street 1:154 EXTON SQUARE MALL
Practice Address - Street 2:NEMOURS DUPONT PEDIATRICS, EXTON
Practice Address - City:EXTON
Practice Address - State:PA
Practice Address - Zip Code:19341-2440
Practice Address - Country:US
Practice Address - Phone:484-565-8507
Practice Address - Fax:610-280-1531
Is Sole Proprietor?:No
Enumeration Date:2009-05-05
Last Update Date:2015-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD446432208000000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA23-2359401OtherMAIN LINE HEALTHCARE TAX ID
PA245674HK1Medicare PIN