Basic Information
| Provider Information | |||||||||
| NPI: | 1952330128 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HEGSTROM | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | TERRENCE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 N ACADEMY AVE | ||||||||
| Address2: | |||||||||
| City: | DANVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 178224903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5702716144 | ||||||||
| FaxNumber: | 5702716578 | ||||||||
| Practice Location | |||||||||
| Address1: | 132 ABIGAIL LANE | ||||||||
| Address2: | |||||||||
| City: | PORT MATILDA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 16870 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8142725011 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/01/2006 | ||||||||
| LastUpdateDate: | 08/11/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 21695 | WV | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | MD444655 | PA | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 3810001358 | 05 | WV | MEDICAID |