Healthcare Provider Details

I. General information

NPI: 1538854062
Provider Name (Legal Business Name): CARTER BAGLEY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2023
Last Update Date: 09/18/2026
Certification Date: 09/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8201 E RIVERSIDE BLVD
ROCKFORD IL
61114-2300
US

IV. Provider business mailing address

29624 NETWORK PL
CHICAGO IL
60673-1296
US

V. Phone/Fax

Practice location:
  • Phone: 815-971-7000
  • Fax:
Mailing address:
  • Phone: 608-756-6278
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number036178562
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number01099311A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number85312
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: