Healthcare Provider Details

I. General information

NPI: 1043419666
Provider Name (Legal Business Name): TYLER BAGLEY VEREEN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TYLER ALLISON BAGLEY MD

II. Dates (important events)

Enumeration Date: 07/13/2007
Last Update Date: 10/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 FACILITY DR
CLYDE NC
28721-9438
US

IV. Provider business mailing address

15 FACILITY DR
CLYDE NC
28721-9438
US

V. Phone/Fax

Practice location:
  • Phone: 828-452-2211
  • Fax: 828-452-4421
Mailing address:
  • Phone: 828-452-2211
  • Fax: 828-452-4421

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberLL29898
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2012-01881
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: