Provider Demographics
NPI:1952330128
Name:HEGSTROM, MICHAEL TERRENCE (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:TERRENCE
Last Name:HEGSTROM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:100 N ACADEMY AVE
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17822-4903
Mailing Address - Country:US
Mailing Address - Phone:570-271-6144
Mailing Address - Fax:570-271-6578
Practice Address - Street 1:132 ABIGAIL LANE
Practice Address - Street 2:
Practice Address - City:PORT MATILDA
Practice Address - State:PA
Practice Address - Zip Code:16870
Practice Address - Country:US
Practice Address - Phone:814-272-5011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-01
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV21695208600000X
PAMD444655208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810001358Medicaid
WVH34892Medicare UPIN
WV4154551Medicare ID - Type Unspecified