Provider Demographics
NPI:1053396358
Name:HAGENBUCH, MICHELLE L (MD)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:L
Last Name:HAGENBUCH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 PLAZA CIRCLE
Mailing Address - Street 2:SUITE J
Mailing Address - City:CLINTON
Mailing Address - State:SC
Mailing Address - Zip Code:29325
Mailing Address - Country:US
Mailing Address - Phone:864-938-9690
Mailing Address - Fax:864-833-9039
Practice Address - Street 1:500 PLAZA CIRCLE
Practice Address - Street 2:SUITE J
Practice Address - City:CLINTON
Practice Address - State:SC
Practice Address - Zip Code:29325
Practice Address - Country:US
Practice Address - Phone:864-938-9690
Practice Address - Fax:864-833-9039
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-08
Last Update Date:2007-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC150473207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC150473Medicaid