Provider Demographics
NPI:1689671331
Name:HAGEN, EDWARD PAUL (DO)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:PAUL
Last Name:HAGEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:265 GRIFFIN ST E
Mailing Address - Street 2:
Mailing Address - City:AMERY
Mailing Address - State:WI
Mailing Address - Zip Code:54001-1439
Mailing Address - Country:US
Mailing Address - Phone:715-268-8000
Mailing Address - Fax:715-268-0311
Practice Address - Street 1:265 GRIFFIN ST E
Practice Address - Street 2:
Practice Address - City:AMERY
Practice Address - State:WI
Practice Address - Zip Code:54001-1439
Practice Address - Country:US
Practice Address - Phone:715-268-8000
Practice Address - Fax:715-268-0311
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2010-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02734207V00000X
SD3890207V00000X
WI54529207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIE44039Medicare UPIN
160031587Medicare ID - Type UnspecifiedRAILROAD MEDICARE