Basic Information
| Provider Information | |||||||||
| NPI: | 1831184449 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HAGERTY | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | A. | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6805 ROUTE 9 | ||||||||
| Address2: | SUITE 31 | ||||||||
| City: | RHINEBECK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 125721148 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8458763868 | ||||||||
| FaxNumber: | 8458763756 | ||||||||
| Practice Location | |||||||||
| Address1: | 117 MARYS AVE | ||||||||
| Address2: | SUITE 204 | ||||||||
| City: | KINGSTON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 124015849 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8453380789 | ||||||||
| FaxNumber: | 8453349150 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2005 | ||||||||
| LastUpdateDate: | 12/16/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208200000X | 2017201 | NY | Y | Allopathic & Osteopathic Physicians | Plastic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 01649834 | 05 | NY | MEDICAID |