1366439572 NPI number — DR. BEAU J BAGLEY MD

Table of content: DR. BEAU J BAGLEY MD (NPI 1366439572)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366439572 NPI number — DR. BEAU J BAGLEY MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BAGLEY
Provider First Name:
BEAU
Provider Middle Name:
J
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:
1366439572
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/30/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2013
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MANDEVILLE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70470-2013
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
504-237-1430
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1331 OCHSNER BLVD
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
COVINGTON
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70433-8177
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
985-234-0490
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/03/2005

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: 208100000X , with the licence number:  14743R , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208100000X , with the licence number: 26611 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 009932699 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 051528942 . This is a "BCBS PROVIDER NUMBER" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".




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