Provider Demographics
NPI:1568463057
Name:HAGERTY, REBECCA (DO)
Entity Type:Individual
Prefix:DR
First Name:REBECCA
Middle Name:
Last Name:HAGERTY
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 1:1200 SIXTH ST
Mailing Address - Street 2:STE 400
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-2369
Mailing Address - Country:US
Mailing Address - Phone:231-392-0650
Mailing Address - Fax:231-392-0665
Practice Address - Street 1:1200 SIXTH ST
Practice Address - Street 2:STE 400
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-2369
Practice Address - Country:US
Practice Address - Phone:231-392-0650
Practice Address - Fax:231-392-0665
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2008-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIRV013390207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4989078Medicaid
MIG79566Medicare UPIN
MI4989078Medicaid