1740489970 NPI number — JOHN HAGAN CRNP

Table of content: JOHN HAGAN CRNP (NPI 1740489970)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740489970 NPI number — JOHN HAGAN CRNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HAGAN
Provider First Name:
JOHN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNP
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1740489970
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/28/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 64442
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BALTIMORE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21264-4442
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-328-8040
Provider Business Mailing Address Fax Number:
443-462-3514

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
827 LINDEN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BALTIMORE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21201-4606
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-328-8141
Provider Business Practice Location Address Fax Number:
410-328-0177
Provider Enumeration Date:
07/17/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LC0200X , with the licence number:  R079848 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: S062-0376 . This is a "BLUE CROSS REGIONAL" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 419031900 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 960548-01 & 02 . This is a "BLUE CROSS/BLUE SHIELD" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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