Provider Demographics
NPI:1124054275
Name:BAGLEY, LINDA J (MD)
Entity type:Individual
Prefix:
First Name:LINDA
Middle Name:J
Last Name:BAGLEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 SPRUCE STREET
Mailing Address - Street 2:GROUND FLOOR FLOUNDER
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-4206
Mailing Address - Country:US
Mailing Address - Phone:215-662-3005
Mailing Address - Fax:215-662-7011
Practice Address - Street 1:3400 SPRUCE STREET
Practice Address - Street 2:GROUND FLOOR FLOUNDER
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-4206
Practice Address - Country:US
Practice Address - Phone:215-662-3005
Practice Address - Fax:215-662-7011
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2012-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD051842L2085N0700X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0015763600002Medicaid
PA0015763600002Medicaid
PA203185Medicare PIN
G24624Medicare UPIN