Basic Information
| Provider Information | |||||||||
| NPI: | 1396191359 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HAGSTROM | ||||||||
| FirstName: | MICHAEL | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 KISH HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | DEKALB | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601159602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8157667334 | ||||||||
| FaxNumber: | 8157669768 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 KISH HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | DEKALB | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601159602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8157667334 | ||||||||
| FaxNumber: | 8157669768 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/09/2016 | ||||||||
| LastUpdateDate: | 08/03/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 036148007 | IL | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.