Healthcare Provider Details

I. General information

NPI: 1710971734
Provider Name (Legal Business Name): KRISTIN S BAGLEY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KRISTIN S CHARPENTIER M.D.

II. Dates (important events)

Enumeration Date: 09/06/2005
Last Update Date: 08/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7375 W. US 52 NEW PALESTINE FAMILY MEDICINE
NEW PALESTINE IN
46163-8950
US

IV. Provider business mailing address

156 W. MUSKEGON DRIVE
GREENFIELD IN
46140-3069
US

V. Phone/Fax

Practice location:
  • Phone: 317-861-4171
  • Fax: 317-861-5325
Mailing address:
  • Phone: 317-468-6257
  • Fax: 317-468-6268

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01059143A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: