Provider Demographics
NPI:1134121502
Name:BLEGEN, HALWARD M III (MD)
Entity Type:Individual
Prefix:
First Name:HALWARD
Middle Name:M
Last Name:BLEGEN
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 STATE RD
Mailing Address - Street 2:PO BOX 315
Mailing Address - City:SAGAMORE BEACH
Mailing Address - State:MA
Mailing Address - Zip Code:02562-2362
Mailing Address - Country:US
Mailing Address - Phone:508-888-7221
Mailing Address - Fax:508-888-2062
Practice Address - Street 1:180 STATE RD
Practice Address - Street 2:
Practice Address - City:SAGAMORE BEACH
Practice Address - State:MA
Practice Address - Zip Code:02562-2362
Practice Address - Country:US
Practice Address - Phone:508-888-7221
Practice Address - Fax:508-888-2062
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-15
Last Update Date:2012-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA49939207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0175374Medicaid
B47192Medicare ID - Type Unspecified
MA0175374Medicaid