Provider Demographics
NPI:1366439572
Name:BAGLEY, BEAU J (MD)
Entity Type:Individual
Prefix:DR
First Name:BEAU
Middle Name:J
Last Name:BAGLEY
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 2013
Mailing Address - Street 2:
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70470-2013
Mailing Address - Country:US
Mailing Address - Phone:504-237-1430
Mailing Address - Fax:
Practice Address - Street 1:1331 OCHSNER BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433-8177
Practice Address - Country:US
Practice Address - Phone:985-234-0490
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-03
Last Update Date:2013-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA14743R208100000X
AL26611208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009932699Medicaid
AL051528942OtherBCBS PROVIDER NUMBER
AL051528942OtherBCBS PROVIDER NUMBER