Healthcare Provider Details

I. General information

NPI: 1881955086
Provider Name (Legal Business Name): PARADIGM NEUROLOGICAL SERVICES, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/04/2012
Last Update Date: 06/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21814 NORTHERN BLVD SUITE 101
BAYSIDE NY
11361-3581
US

IV. Provider business mailing address

21814 NORTHERN BLVD SUITE 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 Code2084P2900X
TaxonomyPain Medicine (Psychiatry & Neurology) Physician
License Number132024
License Number StateNY

VIII. Authorized Official

Name: CHARLES H BAGLEY
Title or Position: OWNER
Credential: MD
Phone: 718-229-4868