MEDICARE: MICHAEL CHAD BAGWELL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant	PTA 4035	MS

General Provider Information

NPI Number	:	1326275611
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL CHAD BAGWELL

Provider Business Mailing Address
First Line	:	201 S MARKET ST
Second Line	:
City	:	CHARLESTON
State	:	MS
Zip	:	38921-2236
Country	:	US
Telephone Number	:	662-760-7117
Fax Number	:

Provider Business Practice Location Address
First Line	:	201 S MARKET ST
Second Line	:
City	:	CHARLESTON
State	:	MS
Zip	:	38921-2236
Country	:	US
Telephone Number	:	662-760-7117
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/15/2009
Last Update Date	:	06/16/2011

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