Provider Demographics
NPI:1437126596
Name:HEGARTY, CULLEN B (MD)
Entity Type:Individual
Prefix:
First Name:CULLEN
Middle Name:B
Last Name:HEGARTY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8100 34TH AVE S
Mailing Address - Street 2:MC21110Q
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55425-1672
Mailing Address - Country:US
Mailing Address - Phone:952-883-7172
Mailing Address - Fax:952-883-5395
Practice Address - Street 1:640 JACKSON ST
Practice Address - Street 2:MC 11102F
Practice Address - City:ST PAUL
Practice Address - State:MN
Practice Address - Zip Code:55101-2502
Practice Address - Country:US
Practice Address - Phone:651-254-3456
Practice Address - Fax:651-254-5216
Is Sole Proprietor?:No
Enumeration Date:2006-03-07
Last Update Date:2014-09-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI43032207P00000X
MN41633207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN196320100Medicaid
H01205Medicare UPIN
930001183Medicare ID - Type Unspecified