Basic Information
| Provider Information | |||||||||
| NPI: | 1659586048 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BAGWELL | ||||||||
| FirstName: | SANDRA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 190 RIVERSIDE ST | ||||||||
| Address2: | SUITE 6B | ||||||||
| City: | PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 041031073 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2076612000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 22 BRAMHALL ST | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 04102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2076622179 | ||||||||
| FaxNumber: | 2076626326 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2007 | ||||||||
| LastUpdateDate: | 04/24/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0200X | 012416 | ME | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | 284390099 | 05 | ME | MEDICAID |