Provider Demographics
NPI:1952641367
Name:BAGLEY ORTHOPEDIC TRAUMA & SPORTS MEDICINE LLC
Entity Type:Organization
Organization Name:BAGLEY ORTHOPEDIC TRAUMA & SPORTS MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:C
Authorized Official - Last Name:BAGLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:303-888-5020
Mailing Address - Street 1:5165 W 72ND AVE
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:CO
Mailing Address - Zip Code:80030-5137
Mailing Address - Country:US
Mailing Address - Phone:303-888-5020
Mailing Address - Fax:303-469-6793
Practice Address - Street 1:15378 SPRUCE ST
Practice Address - Street 2:
Practice Address - City:BROOMFIELD
Practice Address - State:CO
Practice Address - Zip Code:80023-8779
Practice Address - Country:US
Practice Address - Phone:303-888-5020
Practice Address - Fax:303-469-6793
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-21
Last Update Date:2013-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO45154207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO89103769Medicaid
CO89103769Medicaid