Basic Information
| Provider Information | |||||||||
| NPI: | 1922392448 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HAGEN | ||||||||
| FirstName: | BENJAMIN | ||||||||
| MiddleName: | G | ||||||||
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| Credential: | MPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2454 W CLAY ST | ||||||||
| Address2: | |||||||||
| City: | SAINT CHARLES | ||||||||
| State: | MO | ||||||||
| PostalCode: | 633012548 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6369164625 | ||||||||
| FaxNumber: | 6369164628 | ||||||||
| Practice Location | |||||||||
| Address1: | 9331 PHOENIX VILLAGE PKWY | ||||||||
| Address2: | |||||||||
| City: | O FALLON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 633684281 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6365614793 | ||||||||
| FaxNumber: | 6365614811 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2011 | ||||||||
| LastUpdateDate: | 06/01/2011 | ||||||||
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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 | 225100000X | 2011014886 | MO | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.