Provider Demographics
NPI: | 1538122163 |
---|---|
Name: | BAGLAN, KATHY L (MD) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | KATHY |
Middle Name: | L |
Last Name: | BAGLAN |
Suffix: | |
Gender: | F |
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: | 11475 OLDE CABIN RD |
Mailing Address - Street 2: | SUITE 200 |
Mailing Address - City: | SAINT LOUIS |
Mailing Address - State: | MO |
Mailing Address - Zip Code: | 63141-7128 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 314-991-8200 |
Mailing Address - Fax: | 314-991-8206 |
Practice Address - Street 1: | 607 S NEW BALLAS RD |
Practice Address - Street 2: | SUITE T-1275 |
Practice Address - City: | SAINT LOUIS |
Practice Address - State: | MO |
Practice Address - Zip Code: | 63141-8222 |
Practice Address - Country: | US |
Practice Address - Phone: | 314-251-6844 |
Practice Address - Fax: | 314-251-4337 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-04-06 |
Last Update Date: | 2017-04-12 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
MO | 2001031798 | 2085R0001X |
IL | 036142185 | 2085R0001X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 2085R0001X | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
MO | 205802606 | Medicaid | |
MO | 205802606 | Medicaid | |
IL | F400359943 | Medicare PIN | |
MO | 027010288 | Medicare PIN | |
MO | 107690013 | Medicare PIN |