Provider Demographics
NPI:1730411430
Name:NICHOLAS G. BAGNOLI DO PA
Entity type:Organization
Organization Name:NICHOLAS G. BAGNOLI DO PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:G
Authorized Official - Last Name:BAGNOLI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:407-210-4251
Mailing Address - Street 1:3869 WINDERLAKES DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32835-2625
Mailing Address - Country:US
Mailing Address - Phone:407-210-4251
Mailing Address - Fax:407-648-0968
Practice Address - Street 1:1220 SLIGH BLVD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-1108
Practice Address - Country:US
Practice Address - Phone:407-210-4251
Practice Address - Fax:407-648-0968
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NICHOLAS G, BAGNOLI DO PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-02-04
Last Update Date:2010-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL252446500Medicaid
FLCW130AMedicare PIN
FLG56949Medicare UPIN