Provider Demographics
NPI:1558390617
Name:BAGNELL, KELLY GARVER (M D)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:GARVER
Last Name:BAGNELL
Suffix:
Gender:F
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 13TH AVE E
Mailing Address - Street 2:
Mailing Address - City:POLSON
Mailing Address - State:MT
Mailing Address - Zip Code:59860-5315
Mailing Address - Country:US
Mailing Address - Phone:406-883-5680
Mailing Address - Fax:406-883-8926
Practice Address - Street 1:6 13TH AVE E
Practice Address - Street 2:
Practice Address - City:POLSON
Practice Address - State:MT
Practice Address - Zip Code:59860-5315
Practice Address - Country:US
Practice Address - Phone:406-883-5680
Practice Address - Fax:406-883-8926
Is Sole Proprietor?:No
Enumeration Date:2006-07-01
Last Update Date:2021-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT8448207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0000024905Medicaid
MTG74596Medicare UPIN