Healthcare Provider Details

I. General information

NPI: 1306100771
Provider Name (Legal Business Name): JONATHAN BAGLEY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/29/2012
Last Update Date: 06/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 N STATE ST DEPARTMENT OF ANESTHESIOLOGY
JACKSON MS
39216-4500
US

IV. Provider business mailing address

2500 N STATE ST DEPARTMENT OF ANESTHESIOLOGY
JACKSON MS
39216-4500
US

V. Phone/Fax

Practice location:
  • Phone: 601-984-5914
  • Fax: 601-984-5915
Mailing address:
  • Phone: 601-984-5914
  • Fax: 601-984-5915

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberT-2531
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: