Provider Demographics
NPI:1558306019
Name:BAGWELL, MICHAEL BRIAN (DO)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:BRIAN
Last Name:BAGWELL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2778 HIGHWAY 51 S
Mailing Address - Street 2:
Mailing Address - City:SENATOBIA
Mailing Address - State:MS
Mailing Address - Zip Code:38668-9403
Mailing Address - Country:US
Mailing Address - Phone:662-560-5966
Mailing Address - Fax:662-560-5969
Practice Address - Street 1:2778 HIGHWAY 51 S
Practice Address - Street 2:
Practice Address - City:SENATOBIA
Practice Address - State:MS
Practice Address - Zip Code:38668-9403
Practice Address - Country:US
Practice Address - Phone:662-560-5966
Practice Address - Fax:662-560-5969
Is Sole Proprietor?:No
Enumeration Date:2006-06-18
Last Update Date:2021-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS19146207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08085016Medicaid
MSI65621Medicare UPIN