Basic Information
| Provider Information | |||||||||
| NPI: | 1558303511 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HAGAN | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1836 LACKLAND HILL PKWY | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631463572 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3149890300 | ||||||||
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| Practice Location | |||||||||
| Address1: | 621 S NEW BALLAS RD | ||||||||
| Address2: | SUITE 611A | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631418232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3142516587 | ||||||||
| FaxNumber: | 3142514775 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2006 | ||||||||
| LastUpdateDate: | 02/27/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208200000X | 2002014082 | MO | Y | Allopathic & Osteopathic Physicians | Plastic Surgery |
ID Information
| ID | Type | State | Issuer | Description | P00343197 | 01 | MO | RR MEDICARE | OTHER |