Provider Demographics
NPI:1982616348
Name:BAGWELL, HEIDI M (MD)
Entity Type:Individual
Prefix:
First Name:HEIDI
Middle Name:M
Last Name:BAGWELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:HEIDI
Other - Middle Name:M
Other - Last Name:MIDDENDORF BAGWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1711 S STATE ROAD 135
Mailing Address - Street 2:SUITE C
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46143-6480
Mailing Address - Country:US
Mailing Address - Phone:317-881-7400
Mailing Address - Fax:317-881-7477
Practice Address - Street 1:3000 S STATE ROAD 135 STE 310
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46143-5527
Practice Address - Country:US
Practice Address - Phone:317-497-2400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01060982A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200527050Medicaid