1689804254 NPI number — MR. RONALD DEMETRIC BAGLEY IDMT

Table of content: MR. RONALD DEMETRIC BAGLEY IDMT (NPI 1689804254)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689804254 NPI number — MR. RONALD DEMETRIC BAGLEY IDMT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BAGLEY
Provider First Name:
RONALD
Provider Middle Name:
DEMETRIC
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
IDMT
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:
1689804254
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/17/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PSC 3 BOX 3231
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
APO
Provider Business Mailing Address State Name:
AP
Provider Business Mailing Address Postal Code:
96266-0032
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
01086809949
Provider Business Mailing Address Fax Number:
312-784-3468

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
51 MDOS/ SGOE
Provider Second Line Business Practice Location Address:
BLDG. 777 UNIT 2060
Provider Business Practice Location Address City Name:
APO
Provider Business Practice Location Address State Name:
AP
Provider Business Practice Location Address Postal Code:
96278-2060
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
312-784-2500
Provider Business Practice Location Address Fax Number:
312-784-3468
Provider Enumeration Date:
07/17/2009

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: 1710I1003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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