Provider Demographics
NPI:1205817996
Name:HAZELRIGG, STEPHEN R (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:R
Last Name:HAZELRIGG
Suffix:
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:PO BOX 19638
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62794-9638
Mailing Address - Country:US
Mailing Address - Phone:217-545-7422
Mailing Address - Fax:217-545-7053
Practice Address - Street 1:315 W CARPENTER ST
Practice Address - Street 2:2ND FLOOR
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-4901
Practice Address - Country:US
Practice Address - Phone:217-545-7422
Practice Address - Fax:217-545-7053
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036072099208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036072099Medicaid
IL256510Medicare PIN
ILL60186Medicare PIN
IL036072099Medicaid