Provider Demographics
NPI:1710971734
Name:BAGLEY, KRISTIN S (MD)
Entity Type:Individual
Prefix:DR
First Name:KRISTIN
Middle Name:S
Last Name:BAGLEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:KRISTIN
Other - Middle Name:S
Other - Last Name:CHARPENTIER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:156 W. MUSKEGON DRIVE
Mailing Address - Street 2:
Mailing Address - City:GREENFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46140-3069
Mailing Address - Country:US
Mailing Address - Phone:317-468-6257
Mailing Address - Fax:317-468-6268
Practice Address - Street 1:7375 W. US 52
Practice Address - Street 2:NEW PALESTINE FAMILY MEDICINE
Practice Address - City:NEW PALESTINE
Practice Address - State:IN
Practice Address - Zip Code:46163-8950
Practice Address - Country:US
Practice Address - Phone:317-861-4171
Practice Address - Fax:317-861-5325
Is Sole Proprietor?:No
Enumeration Date:2005-09-06
Last Update Date:2014-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01059143A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200311740AMedicaid
IN200483160Medicaid
IN000000332737OtherANTHEM PIN#
IN7278588OtherAETNA PIN#
IN7278588OtherAETNA PIN#
IN200483160Medicaid