Basic Information
| Provider Information | |||||||||
| NPI: | 1578088316 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BAGLEY | ||||||||
| FirstName: | ANDREW | ||||||||
| MiddleName: | MARTIN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 306393 | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372306393 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153731350 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 915 FOLLY RD STE J | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294123907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8432036955 | ||||||||
| FaxNumber: | 8438054908 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2017 | ||||||||
| LastUpdateDate: | 05/10/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | SC | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 207PS0010X | LAT-3124 | NC | N | Allopathic & Osteopathic Physicians | Emergency Medicine | Sports Medicine |
No ID Information.