Provider Demographics
NPI:1679529879
Name:HAGEDORN, JEFFREY C (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:C
Last Name:HAGEDORN
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:PO BOX 775383
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-5383
Mailing Address - Country:US
Mailing Address - Phone:812-376-5315
Mailing Address - Fax:812-375-3477
Practice Address - Street 1:2138 25TH ST STE F
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:IN
Practice Address - Zip Code:47201-3241
Practice Address - Country:US
Practice Address - Phone:812-376-3100
Practice Address - Fax:812-378-6191
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2024-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01028132A2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP01163092OtherRAILROAD MEDICARE
IN000000990875OtherANTHEM PIN
IN100138970Medicaid
INP01163092OtherRAILROAD MEDICARE
IN100138970Medicaid
ININ1105003Medicare PIN
ININ1106003Medicare PIN