Provider Demographics
NPI:1922392448
Name:HAGEN, BENJAMIN G (MPT)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:G
Last Name:HAGEN
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2454 W CLAY ST
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63301-2548
Mailing Address - Country:US
Mailing Address - Phone:636-916-4625
Mailing Address - Fax:636-916-4628
Practice Address - Street 1:9331 PHOENIX VILLAGE PKWY
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63368-4281
Practice Address - Country:US
Practice Address - Phone:636-561-4793
Practice Address - Fax:636-561-4811
Is Sole Proprietor?:No
Enumeration Date:2011-06-01
Last Update Date:2011-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011014886225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist