Provider Demographics
NPI:1982683868
Name:HAGEN, MICHAEL WAYNE (DO)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:WAYNE
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 1:8682 AUDRIAN COUNTRY RD
Mailing Address - Street 2:ROAD 353
Mailing Address - City:MEXICO
Mailing Address - State:MO
Mailing Address - Zip Code:65265
Mailing Address - Country:US
Mailing Address - Phone:573-581-4107
Mailing Address - Fax:
Practice Address - Street 1:620 E MONROE
Practice Address - Street 2:
Practice Address - City:MEXICO
Practice Address - State:MO
Practice Address - Zip Code:65265
Practice Address - Country:US
Practice Address - Phone:573-582-4000
Practice Address - Fax:573-582-3712
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2020-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO36548208000000X, 207P00000X, 207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO36548OtherSTATE LICENSE
136050005Medicare ID - Type Unspecified
MO36548OtherSTATE LICENSE