Healthcare Provider Details

I. General information

NPI: 1558306019
Provider Name (Legal Business Name): MICHAEL BRIAN BAGWELL D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2006
Last Update Date: 07/01/2021
Certification Date: 07/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2778 HIGHWAY 51 S
SENATOBIA MS
38668-9403
US

IV. Provider business mailing address

2778 HIGHWAY 51 S
SENATOBIA MS
38668-9403
US

V. Phone/Fax

Practice location:
  • Phone: 662-560-5966
  • Fax: 662-560-5969
Mailing address:
  • Phone: 662-560-5966
  • Fax: 662-560-5969

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number19146
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number19146
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: