Provider Demographics
NPI:1659362077
Name:HAGAN, MARY ARNDT (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:ARNDT
Last Name:HAGAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 S BRUCE ST
Mailing Address - Street 2:AVERA MARSHALL
Mailing Address - City:MARSHALL
Mailing Address - State:MN
Mailing Address - Zip Code:56258-1934
Mailing Address - Country:US
Mailing Address - Phone:507-537-9007
Mailing Address - Fax:507-537-2720
Practice Address - Street 1:300 S BRUCE ST
Practice Address - Street 2:AVERA MARSHALL
Practice Address - City:MARSHALL
Practice Address - State:MN
Practice Address - Zip Code:56258-1934
Practice Address - Country:US
Practice Address - Phone:507-537-9007
Practice Address - Fax:507-537-2720
Is Sole Proprietor?:No
Enumeration Date:2005-11-03
Last Update Date:2015-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN58575208000000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI501782OtherTOUCHPOINT
WIWI01P1OtherJOHN DEERE
WI12805OtherDEAN
WI39080723696OtherBLUE CROSS BLUE SHIELD
WI34051400Medicaid
WI34051400Medicaid
F24707Medicare UPIN