Provider Demographics
NPI:1851352454
Name:BAGNER, MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:BAGNER
Suffix:
Gender:M
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:PO BOX 95000-2409
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19195-0001
Mailing Address - Country:US
Mailing Address - Phone:212-641-4500
Mailing Address - Fax:212-641-4510
Practice Address - Street 1:780 8TH AVE
Practice Address - Street 2:SUITE 303
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10036-7017
Practice Address - Country:US
Practice Address - Phone:212-641-4500
Practice Address - Fax:212-641-4510
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2014-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY188015207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
E66943Medicare UPIN