Provider Demographics
NPI:1578090270
Name:KENNECKE, HAGEN (MD, MHA, FRCPC)
Entity Type:Individual
Prefix:DR
First Name:HAGEN
Middle Name:
Last Name:KENNECKE
Suffix:
Gender:M
Credentials:MD, MHA, FRCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 SW 5TH AVE STE 500
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97201-5537
Mailing Address - Country:US
Mailing Address - Phone:866-617-6855
Mailing Address - Fax:503-346-8015
Practice Address - Street 1:1130 NW 22ND AVE STE 150
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-2974
Practice Address - Country:US
Practice Address - Phone:971-262-9600
Practice Address - Fax:971-262-9601
Is Sole Proprietor?:No
Enumeration Date:2017-05-12
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60729732207RH0003X
ORMD203393207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
No207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology