Healthcare Provider Details

I. General information

NPI: 1568496115
Provider Name (Legal Business Name): CHARLES H BAGLEY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 05/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21814 NORTHERN BLVD 101
BAYSIDE NY
11361-3581
US

IV. Provider business mailing address

21814 NORTHERN BLVD 101
BAYSIDE NY
11361-3581
US

V. Phone/Fax

Practice location:
  • Phone: 718-229-4868
  • Fax:
Mailing address:
  • Phone: 718-229-4868
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number132024
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: