Healthcare Provider Details

I. General information

NPI: 1366439572
Provider Name (Legal Business Name): BEAU J BAGLEY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2005
Last Update Date: 03/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1331 OCHSNER BLVD SUITE 100
COVINGTON LA
70433-8177
US

IV. Provider business mailing address

PO BOX 2013
MANDEVILLE LA
70470-2013
US

V. Phone/Fax

Practice location:
  • Phone: 985-234-0490
  • Fax:
Mailing address:
  • Phone: 504-237-1430
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number14743R
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number26611
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: