Basic Information
| Provider Information | |||||||||
| NPI: | 1346417912 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HAGAN | ||||||||
| FirstName: | MATILDA | ||||||||
| MiddleName: | NANA AMBA | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 301 SAINT PAUL PL | ||||||||
| Address2: | MEDICAL STAFF OFFICE | ||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212022102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4106592802 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 301 SAINT PAUL PL | ||||||||
| Address2: | POB 718 | ||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212022102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4103329356 | ||||||||
| FaxNumber: | 4107835884 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/13/2008 | ||||||||
| LastUpdateDate: | 09/09/2014 | ||||||||
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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 | 207RG0100X | D0078377 | MD | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
No ID Information.