Provider Demographics
NPI:1659478436
Name:HAGSTROM, MICHELLE T (MD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:T
Last Name:HAGSTROM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10390 ROWLOCK WAY
Mailing Address - Street 2:
Mailing Address - City:PARKER
Mailing Address - State:CO
Mailing Address - Zip Code:80134-9578
Mailing Address - Country:US
Mailing Address - Phone:720-838-8832
Mailing Address - Fax:
Practice Address - Street 1:2525 S DOWNING ST
Practice Address - Street 2:EMERGENCY DEPT
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80210-5817
Practice Address - Country:US
Practice Address - Phone:720-283-6700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2015-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.119966207P00000X
CO50851207P00000X
MO2011040062207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO209880608Medicaid
MO209880608Medicaid
I69871Medicare UPIN
MO964434740Medicare PIN