Healthcare Provider Details

I. General information

NPI: 1194267757
Provider Name (Legal Business Name): MICHAEL DAGGY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2016
Last Update Date: 02/04/2021
Certification Date: 02/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

642 W HOSPITAL RD
PAOLI IN
47454-9672
US

IV. Provider business mailing address

642 W HOSPITAL RD
PAOLI IN
47454-9672
US

V. Phone/Fax

Practice location:
  • Phone: 812-723-7451
  • Fax: 812-723-7508
Mailing address:
  • Phone: 812-723-7451
  • Fax: 812-723-7508

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number71006837A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: