Provider Demographics
NPI:1205013547
Name:DR. GREGORY B. HAGEDORN, OD
Entity Type:Organization
Organization Name:DR. GREGORY B. HAGEDORN, OD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:RUTHERFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-826-1500
Mailing Address - Street 1:PO BOX 577
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:KY
Mailing Address - Zip Code:42419-0577
Mailing Address - Country:US
Mailing Address - Phone:270-826-1500
Mailing Address - Fax:270-827-0757
Practice Address - Street 1:1413 N ELM ST
Practice Address - Street 2:SUITE 102
Practice Address - City:HENDERSON
Practice Address - State:KY
Practice Address - Zip Code:42420-2768
Practice Address - Country:US
Practice Address - Phone:270-826-1500
Practice Address - Fax:270-827-0757
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-29
Last Update Date:2009-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1016DT332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY0425620001Medicare NSC