Basic Information
| Provider Information | |||||||||
| NPI: | 1245203306 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HAGAN | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | N | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1493 CAMBRIDGE ST | ||||||||
| Address2: | |||||||||
| City: | CAMBRIDGE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021391047 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6176651616 | ||||||||
| FaxNumber: | 6176651976 | ||||||||
| Practice Location | |||||||||
| Address1: | 119 WINDSOR ST | ||||||||
| Address2: | WINDSOR STREET HEALTH CENTER | ||||||||
| City: | CAMBRIDGE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021393647 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6176653600 | ||||||||
| FaxNumber: | 6176653603 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2006 | ||||||||
| LastUpdateDate: | 11/21/2011 | ||||||||
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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 | 208000000X | 70814 | MA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 714861 | 01 | TUFTS | OTHER | J09328 | 01 | BCBS | OTHER | 3091562 | 05 | MA | MEDICAID |