Provider Demographics
NPI:1245307552
Name:HAGEN, JOHN M (DC)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:M
Last Name:HAGEN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6435 NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60302-1013
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6435 NORTH AVE
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60302-1013
Practice Address - Country:US
Practice Address - Phone:708-848-7766
Practice Address - Fax:708-848-5577
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2009-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038007932111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL038007932Medicaid
565950Medicare ID - Type Unspecified
IL038007932Medicaid