1225196363 NPI number — DAVID J. HAGSTROM LLC

Table of content: (NPI 1225196363)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225196363 NPI number — DAVID J. HAGSTROM LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DAVID J. HAGSTROM LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1225196363
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2112 VIKING DR NW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROCHESTER
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55901-3522
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
507-288-1744
Provider Business Mailing Address Fax Number:
507-292-5776

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2112 VIKING DR NW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROCHESTER
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55901-3522
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
507-288-1744
Provider Business Practice Location Address Fax Number:
507-292-5776
Provider Enumeration Date:
12/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HAGSTROM
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
JEROME
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
507-288-1744

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  D11449 , 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: 39492MA . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 9175780 . This is a "DORAL DENTAL IDENTIFIER" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: D11449 . This is a "LICENSE NUMBER" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 1348318 . This is a "TRI CARE ID NUMBER" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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