Basic Information
| Provider Information | |||||||||
| NPI: | 1710971734 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BAGLEY | ||||||||
| FirstName: | KRISTIN | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CHARPENTIER | ||||||||
| OtherFirstName: | KRISTIN | ||||||||
| OtherMiddleName: | S | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 156 W. MUSKEGON DRIVE | ||||||||
| Address2: | |||||||||
| City: | GREENFIELD | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461403069 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3174686257 | ||||||||
| FaxNumber: | 3174686268 | ||||||||
| Practice Location | |||||||||
| Address1: | 7375 W. US 52 | ||||||||
| Address2: | NEW PALESTINE FAMILY MEDICINE | ||||||||
| City: | NEW PALESTINE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461638950 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3178614171 | ||||||||
| FaxNumber: | 3178615325 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/06/2005 | ||||||||
| LastUpdateDate: | 08/06/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 01059143A | IN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200311740A | 05 | IN | MEDICAID | 200483160 | 05 | IN | MEDICAID | 000000332737 | 01 | IN | ANTHEM PIN# | OTHER | 7278588 | 01 | IN | AETNA PIN# | OTHER |