Provider Demographics
NPI:1053413807
Name:VANESSA HAGAN, MD, SC
Entity type:Organization
Organization Name:VANESSA HAGAN, MD, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:VANESSA
Authorized Official - Middle Name:
Authorized Official - Last Name:HAGAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-423-1300
Mailing Address - Street 1:4400 W 95TH ST
Mailing Address - Street 2:303
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-2654
Mailing Address - Country:US
Mailing Address - Phone:708-423-1300
Mailing Address - Fax:708-423-6085
Practice Address - Street 1:4400 W 95TH ST
Practice Address - Street 2:303
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-2654
Practice Address - Country:US
Practice Address - Phone:708-423-1300
Practice Address - Fax:708-423-6085
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========6045301Medicaid
ILI14475Medicare UPIN
IL=========6045301Medicaid