1699738260 NPI number — MAURA KELLY HAGAN M.D.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699738260 NPI number — MAURA KELLY HAGAN M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HAGAN
Provider First Name:
MAURA
Provider Middle Name:
KELLY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

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:
1699738260
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/21/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7202 GLEN FOREST DR
Provider Second Line Business Mailing Address:
STE 200
Provider Business Mailing Address City Name:
RICHMOND
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23226-3781
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
804-673-0134
Provider Business Mailing Address Fax Number:
804-673-1796

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7501 RIGHT FLANK RD
Provider Second Line Business Practice Location Address:
SUITE 600
Provider Business Practice Location Address City Name:
MECHANICSVILLE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23116-1815
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
804-559-2489
Provider Business Practice Location Address Fax Number:
804-730-5847
Provider Enumeration Date:
04/06/2006

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: 207RH0003X , with the licence number:  0101047847 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 110056024 . This is a "RR MEDICARE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 006083901 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 237410 . This is a "ANTHEM BCBS VA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: C01120 . This is a "MEDICARE GROUP PTAN" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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