1114910049 NPI number — DR. GAIL HEGEMAN PH D

Table of content: DR. GAIL HEGEMAN PH D (NPI 1114910049)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114910049 NPI number — DR. GAIL HEGEMAN PH D

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HEGEMAN
Provider First Name:
GAIL
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PH D
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HEGEMAN
Provider Other First Name:
GAIL
Provider Other Middle Name:
M
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
PH D
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1114910049
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/13/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1711 COUNTY ROAD B WEST
Provider Second Line Business Mailing Address:
SUITE 144S
Provider Business Mailing Address City Name:
ROSEVILLE
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55113-4100
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-635-0909
Provider Business Mailing Address Fax Number:
612-822-8669

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1711 COUNTY ROAD B WEST
Provider Second Line Business Practice Location Address:
SUITE 144S
Provider Business Practice Location Address City Name:
ROSEVILLE
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55113-4100
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-635-0909
Provider Business Practice Location Address Fax Number:
612-822-8669
Provider Enumeration Date:
08/25/2005

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: 103TC0700X , with the licence number:  LP2464 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 30269000 . This is a "MAGELLAN BEHAVIOR HEALTH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 59123AR . This is a "BCBS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 59125HE . This is a "BCBS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 642047800 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6113193 . This is a "UNITED BEHAVIORAL HEALTH" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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