1467183236 NPI number — MATT STEPHEN HAZELRIGG MD

Table of content: MATT STEPHEN HAZELRIGG MD (NPI 1467183236)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467183236 NPI number — MATT STEPHEN HAZELRIGG MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HAZELRIGG
Provider First Name:
MATT
Provider Middle Name:
STEPHEN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1467183236
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/01/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1458 N BOSWORTH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60642-2380
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
217-899-1888
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
20201 CRAWFORD AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OLYMPIA FIELDS
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60461-1010
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-747-4000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/22/2022

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: 208000000X , with the licence number:  125080757 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208600000X , with the licence number: 125080757 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207P00000X , with the licence number: 125080757 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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