Basic Information
| Provider Information | |||||||||
| NPI: | 1851475180 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HEDGREN | ||||||||
| FirstName: | DIVYA | ||||||||
| MiddleName: | G. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1670 UPHAM DR | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432101250 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6142939600 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1670 UPHAM DR | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432101250 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6142939600 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2006 | ||||||||
| LastUpdateDate: | 08/06/2013 | ||||||||
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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 | 2084P0800X | LL28080 | SC | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0800X | 28080 | SC | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0805X | 35.09601 | OH | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Geriatric Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 280805 | 05 | SC | MEDICAID | 0055610 | 05 | OH | MEDICAID |