Provider Demographics
NPI:1063894590
Name:HAGENAUER, ANDREW (DO)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:HAGENAUER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-522-8614
Mailing Address - Fax:
Practice Address - Street 1:10110 CLEMSON BLVD
Practice Address - Street 2:
Practice Address - City:SENECA
Practice Address - State:SC
Practice Address - Zip Code:29678-0812
Practice Address - Country:US
Practice Address - Phone:864-482-3148
Practice Address - Fax:864-482-0505
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-21
Last Update Date:2020-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCLL37689207Q00000X
SC37689207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine