Provider Demographics
NPI:1659586048
Name:BAGWELL, SANDRA (MD)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:BAGWELL
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 1:190 RIVERSIDE ST
Mailing Address - Street 2:SUITE 6B
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-1073
Mailing Address - Country:US
Mailing Address - Phone:207-661-2000
Mailing Address - Fax:
Practice Address - Street 1:22 BRAMHALL ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102
Practice Address - Country:US
Practice Address - Phone:207-662-2179
Practice Address - Fax:207-662-6326
Is Sole Proprietor?:No
Enumeration Date:2007-05-11
Last Update Date:2017-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME012416207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME284390099Medicaid
MEMM289001Medicare PIN
ME284390099Medicaid