Provider Demographics
NPI:1891726386
Name:MAURA BAGOS, D.O., P.C.
Entity Type:Organization
Organization Name:MAURA BAGOS, D.O., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:MAURA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:BAGOS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:248-244-8545
Mailing Address - Street 1:2701 TROY CENTER DR STE 260
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48084-4741
Mailing Address - Country:US
Mailing Address - Phone:248-244-8545
Mailing Address - Fax:248-244-8582
Practice Address - Street 1:2701 TROY CENTER DR STE 260
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084-4741
Practice Address - Country:US
Practice Address - Phone:248-244-8545
Practice Address - Fax:248-244-8582
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-05
Last Update Date:2008-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIMB011649207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4130308Medicaid
MI1156303474OtherBCBSM
MI1156303474OtherBCBSM
MI=========OtherCOMMERCIAL