MEDICARE: TIMOTHY D FAGEN D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208D00000X	General Practice Physician	5101017047	MI
2	208D00000X	General Practice Physician	DOS 1120	HI
3	207ZP0102X	Anatomic Pathology & Clinical Pathology Physician	2010014000	MO

General Provider Information

NPI Number	:	1750315958
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TIMOTHY D FAGEN D.O.

Provider Business Mailing Address
First Line	:	1402 S GRAND BLVD STE M260
Second Line	:	ST LOUIS UNIVERSITY GME
City	:	SAINT LOUIS
State	:	MO
Zip	:	63104-1004
Country	:	US
Telephone Number	:	314-577-8782
Fax Number	:

Provider Business Practice Location Address
First Line	:	1402 S GRAND BLVD STE M260
Second Line	:	ST LOUIS UNIVERSITY GME
City	:	SAINT LOUIS
State	:	MO
Zip	:	63104-1004
Country	:	US
Telephone Number	:	314-577-8782
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/11/2006
Last Update Date	:	08/11/2010

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