1366417479 NPI number — DR. CHARLES A BAGWELL MD

Table of content: DR. CHARLES A BAGWELL MD (NPI 1366417479)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366417479 NPI number — DR. CHARLES A BAGWELL MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BAGWELL
Provider First Name:
CHARLES
Provider Middle Name:
A
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1366417479
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1100 WARD STREET EXT W
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DOUGLAS
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31533-1902
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
912-384-1477
Provider Business Mailing Address Fax Number:
912-384-1470

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 DOCTORS DR STE C
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DOUGLAS
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31533-2211
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
912-384-5832
Provider Business Practice Location Address Fax Number:
912-383-8279
Provider Enumeration Date:
02/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  050494 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 11D1105865 . This is a "CLIA ID - 17 JOHNSON ST" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 341153 . This is a "WELLCARE OF GEORGIA" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 000919729B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000919729C , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 050494 . This is a "GA LICENSE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 050494 . This is a "MEDICAL LICENSE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 11D0265294 . This is a "CLIA ID - 1309 OCILLA RD STE A" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: PTAN P00473716 . This is a "RAILROAD MEDICARE - PALMETTO GBA" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 129049 . This is a "PEACHSTATE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: GROUP #DH1281 . This is a "RAILROAD MEDICARE - PALMETTO GBA" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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