Healthcare Provider Details

I. General information

NPI: 1659586048
Provider Name (Legal Business Name): SANDRA BAGWELL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2007
Last Update Date: 04/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 BRAMHALL ST
PORTLAND ME
04102
US

IV. Provider business mailing address

190 RIVERSIDE ST SUITE 6B
PORTLAND ME
04103-1073
US

V. Phone/Fax

Practice location:
  • Phone: 207-662-2179
  • Fax: 207-662-6326
Mailing address:
  • Phone: 207-661-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number012416
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: