Provider Demographics
NPI:1518935261
Name:HAGEN, BRENDA L (DO)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:L
Last Name:HAGEN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 SPRING FOREST RD
Mailing Address - Street 2:SUITE 130
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27616-2880
Mailing Address - Country:US
Mailing Address - Phone:919-882-0705
Mailing Address - Fax:919-873-9821
Practice Address - Street 1:555 E CHEVES ST
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29506-2617
Practice Address - Country:US
Practice Address - Phone:843-661-6215
Practice Address - Fax:919-873-9821
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2016-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34004110207L00000X
SC36203207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0636162Medicaid
OH0636162Medicaid
OHHA0777003Medicare ID - Type Unspecified