Provider Demographics
NPI:1245237825
Name:HAGEDORN, ANN (MD)
Entity Type:Individual
Prefix:
First Name:ANN
Middle Name:
Last Name:HAGEDORN
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 1:4550 MEMORIAL DR
Mailing Address - Street 2:STE 340
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62226-5372
Mailing Address - Country:US
Mailing Address - Phone:618-257-6200
Mailing Address - Fax:618-257-6679
Practice Address - Street 1:200 HEALTH CARE DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:IL
Practice Address - Zip Code:62246-1154
Practice Address - Country:US
Practice Address - Phone:618-664-1230
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-28
Last Update Date:2019-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036106952208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036106952Medicaid
IL1245237825Medicaid
ILH70504Medicare UPIN
IL036106952Medicaid