Provider Demographics
NPI:1346328226
Name:HAGENSTEIN, HENRY (DO)
Entity Type:Individual
Prefix:
First Name:HENRY
Middle Name:
Last Name:HAGENSTEIN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3635 GENESYS PKWY
Mailing Address - Street 2:
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-8067
Mailing Address - Country:US
Mailing Address - Phone:810-606-0682
Mailing Address - Fax:810-606-0686
Practice Address - Street 1:3635 GENESYS PKWY
Practice Address - Street 2:
Practice Address - City:GRAND BLANC
Practice Address - State:MI
Practice Address - Zip Code:48439-8067
Practice Address - Country:US
Practice Address - Phone:810-606-0682
Practice Address - Fax:810-606-0686
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2010-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIHH007300174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1586061Medicaid
MIP55250001Medicare PIN
MIE25971Medicare UPIN