Basic Information
| Provider Information | |||||||||
| NPI: | 1699762278 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HAGEMAN | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | S | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10 SAINT PATRICKS DR | ||||||||
| Address2: | SUITE 401 | ||||||||
| City: | WALDORF | ||||||||
| State: | MD | ||||||||
| PostalCode: | 206034527 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3018707366 | ||||||||
| FaxNumber: | 3018706717 | ||||||||
| Practice Location | |||||||||
| Address1: | 22715 WASHINGTON STREET | ||||||||
| Address2: | |||||||||
| City: | LEONARDTOWN | ||||||||
| State: | MD | ||||||||
| PostalCode: | 20650 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3019970172 | ||||||||
| FaxNumber: | 3019970175 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2005 | ||||||||
| LastUpdateDate: | 12/17/2012 | ||||||||
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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 | 17767 | MD | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 796804300 | 05 | MD | MEDICAID |