Provider Demographics
NPI:1093992901
Name:HAGEN, AMY JEAN (DO)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:JEAN
Last Name:HAGEN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4041 RIDGE AVE APT 18412
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19129-1557
Mailing Address - Country:US
Mailing Address - Phone:619-977-3854
Mailing Address - Fax:
Practice Address - Street 1:RED LION RD AT KNIGHTS RD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19114
Practice Address - Country:US
Practice Address - Phone:215-824-2260
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-23
Last Update Date:2010-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOTO11845207P00000X
CA20A11132207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1093992901Medicaid
CADF358ZMedicare PIN