Provider Demographics
NPI:1558349548
Name:HAGAN, KEITH W (MD)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:W
Last Name:HAGAN
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 1:2801 CHARLOTTE AVE
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37209-4035
Mailing Address - Country:US
Mailing Address - Phone:615-250-9200
Mailing Address - Fax:615-250-9251
Practice Address - Street 1:2801 CHARLOTTE AVE
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37209-4035
Practice Address - Country:US
Practice Address - Phone:615-250-9200
Practice Address - Fax:615-250-9251
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD7894208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN2006095OtherBLUE CROSS
TN3173097Medicaid
KY64742182Medicaid
TN3173097Medicaid
TN3173091Medicare ID - Type Unspecified