Provider Demographics
NPI:1134143852
Name:HAGADORN, SCOT E (MD)
Entity type:Individual
Prefix:
First Name:SCOT
Middle Name:E
Last Name:HAGADORN
Suffix:
Gender:M
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:PO BOX 78838
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-0838
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:1701 S CREASY LN
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-4972
Practice Address - Country:US
Practice Address - Phone:765-502-4917
Practice Address - Fax:765-502-4023
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2023-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01042933208VP0000X
IN01042933A207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100386000AMedicaid
INM400053189Medicare PIN
IN100386000AMedicaid