Provider Demographics
NPI:1568499598
Name:HAGELBERG, RICHARD SPENCER (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:SPENCER
Last Name:HAGELBERG
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 1:100 MICHIGAN ST NE
Mailing Address - Street 2:MC 845
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:221 MICHIGAN ST NE STE 400
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2543
Practice Address - Country:US
Practice Address - Phone:616-486-9600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2021-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI047185174400000X
MI43010471852086S0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
05290OtherPARAMOUNT
9137102OtherAETNA
MI4069666Medicaid
000000545164OtherANTHEM
OH2801132Medicaid
MID16150217Medicare PIN
05290OtherPARAMOUNT
MI0M74810Medicare ID - Type Unspecified
OHHA7381351Medicare PIN
E37444Medicare UPIN
OHHA4226851Medicare PIN