Basic Information
| Provider Information | |||||||||
| NPI: | 1164415543 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BAGBY | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | A. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 183 HOSPITAL RD | ||||||||
| Address2: | STE G | ||||||||
| City: | WINCHESTER | ||||||||
| State: | TN | ||||||||
| PostalCode: | 373982470 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9319622272 | ||||||||
| FaxNumber: | 9319678119 | ||||||||
| Practice Location | |||||||||
| Address1: | 183 HOSPITAL RD | ||||||||
| Address2: | STE G | ||||||||
| City: | WINCHESTER | ||||||||
| State: | TN | ||||||||
| PostalCode: | 373982470 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9319622272 | ||||||||
| FaxNumber: | 9319628588 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2005 | ||||||||
| LastUpdateDate: | 09/04/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | MDO11925 | TN | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 407202037 | 01 | RAILROAD MEDICARE | OTHER | 2009891 | 01 | BLUE CROSS | OTHER | 2009891 | 05 | TN | MEDICAID | 621117715 | 01 | TN | AMERICHOICE TENNCARE | OTHER |