Provider Demographics
NPI:1568450732
Name:HAGENOW, CHARLES FREDERICK (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:FREDERICK
Last Name:HAGENOW
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 1:710 N NILES AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-1924
Mailing Address - Country:US
Mailing Address - Phone:574-647-1610
Mailing Address - Fax:
Practice Address - Street 1:714 N MICHIGAN ST
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-1035
Practice Address - Country:US
Practice Address - Phone:574-647-7477
Practice Address - Fax:574-647-3655
Is Sole Proprietor?:No
Enumeration Date:2005-10-11
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01024048A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100364800Medicaid
IN000000202074OtherBCBS BMG E. BLAIR WARNER
IN080127638OtherRR MEDICARE
IN100364800Medicaid
IN000000811896OtherBCBS BMG PORTAGE ROAD
IN000000811896OtherBCBS BMG PORTAGE ROAD
IN162520MMMedicare PIN
IN100364800Medicaid
INC25127Medicare UPIN