Basic Information
| Provider Information | |||||||||
| NPI: | 1164440574 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HAGEN | ||||||||
| FirstName: | ELIZABETH | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4425 N PORT WASHINGTON RD | ||||||||
| Address2: | ATTN: CSMCP CLINIC CREDENTIALING | ||||||||
| City: | GLENDALE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532121082 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2623776933 | ||||||||
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| Practice Location | |||||||||
| Address1: | N143W6515 PIONEER RD | ||||||||
| Address2: | |||||||||
| City: | CEDARBURG | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530122705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2623776933 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2006 | ||||||||
| LastUpdateDate: | 03/26/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 35576 | WI | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 32223300 | 05 | WI | MEDICAID |