Provider Demographics
NPI:1992855894
Name:HAGEDORN, BRIAN PAUL (PT)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:PAUL
Last Name:HAGEDORN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10689 ASHVIEW DR
Mailing Address - Street 2:
Mailing Address - City:FISHERS
Mailing Address - State:IN
Mailing Address - Zip Code:46038-7483
Mailing Address - Country:US
Mailing Address - Phone:317-453-1069
Mailing Address - Fax:
Practice Address - Street 1:10689 ASHVIEW DR
Practice Address - Street 2:
Practice Address - City:FISHERS
Practice Address - State:IN
Practice Address - Zip Code:46038-7483
Practice Address - Country:US
Practice Address - Phone:317-453-1069
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2013-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05002898225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN151560LLMedicare PIN