Provider Demographics
NPI:1518049931
Name:HAGEN, NATHAN B (MD)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:B
Last Name:HAGEN
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 290
Mailing Address - Street 2:115 SO ST
Mailing Address - City:MICHIGAN
Mailing Address - State:ND
Mailing Address - Zip Code:58259-0290
Mailing Address - Country:US
Mailing Address - Phone:701-259-2119
Mailing Address - Fax:701-259-2319
Practice Address - Street 1:115 SOUTH ST
Practice Address - Street 2:MICHIGAN COMMUNITY MEDICAL CLINIC
Practice Address - City:MICHIGAN
Practice Address - State:ND
Practice Address - Zip Code:58259-0290
Practice Address - Country:US
Practice Address - Phone:701-259-2119
Practice Address - Fax:701-259-2319
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2007-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND3113207Q00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND11257Medicaid
33401OtherREFERRING
ND11257Medicaid
977Medicare ID - Type Unspecified
33401OtherREFERRING
NDN977Medicare UPIN