Basic Information
| Provider Information | |||||||||
| NPI: | 1245237825 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HAGEDORN | ||||||||
| FirstName: | ANN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4550 MEMORIAL DR | ||||||||
| Address2: | STE 340 | ||||||||
| City: | BELLEVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622265372 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182576200 | ||||||||
| FaxNumber: | 6182576679 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 HEALTH CARE DR | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622461154 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6186641230 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2005 | ||||||||
| LastUpdateDate: | 05/10/2019 | ||||||||
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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 | 208M00000X | 036106952 | IL | N | Allopathic & Osteopathic Physicians | Hospitalist | 207R00000X | 036106952 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036106952 | 05 | IL | MEDICAID | 1245237825 | 05 | IL | MEDICAID |