Provider Demographics
NPI:1093829343
Name:CHARLES E BAGLEY MDPC
Entity Type:Organization
Organization Name:CHARLES E BAGLEY MDPC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:E
Authorized Official - Last Name:BAGLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-632-7203
Mailing Address - Street 1:PO BOX 220
Mailing Address - Street 2:
Mailing Address - City:ALMA
Mailing Address - State:GA
Mailing Address - Zip Code:31510
Mailing Address - Country:US
Mailing Address - Phone:912-632-7203
Mailing Address - Fax:912-632-6491
Practice Address - Street 1:210 E 16TH STREET
Practice Address - Street 2:
Practice Address - City:ALMA
Practice Address - State:GA
Practice Address - Zip Code:31510
Practice Address - Country:US
Practice Address - Phone:912-632-7203
Practice Address - Fax:912-632-6491
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-17
Last Update Date:2010-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA010858207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000098733AMedicaid
GA000098733AMedicaid
GA110858020AMedicare PIN