Provider Demographics
NPI:1871672923
Name:HAGNELL, SUSAN M (MD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:M
Last Name:HAGNELL
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:PO BOX 735044
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-5044
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:146 E GENEVA SQ
Practice Address - Street 2:
Practice Address - City:LAKE GENEVA
Practice Address - State:WI
Practice Address - Zip Code:53147-9695
Practice Address - Country:US
Practice Address - Phone:262-249-5005
Practice Address - Fax:262-249-7142
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2023-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-090050207V00000X
WI46010207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34436900Medicaid
IL036090050 2Medicaid
WI34436900Medicaid
WI54176 0340Medicare ID - Type Unspecified