Healthcare Provider Details

I. General information

NPI: 1033200167
Provider Name (Legal Business Name): KIMBERLY M FAGAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/27/2006
Last Update Date: 02/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3125 INDEPENDENCE DR SUITE 300A
BIRMINGHAM AL
35209-4159
US

IV. Provider business mailing address

3125 INDEPENDENCE DR SUITE 300A
BIRMINGHAM AL
35209-4159
US

V. Phone/Fax

Practice location:
  • Phone: 205-879-8206
  • Fax: 205-271-3075
Mailing address:
  • Phone: 205-879-8206
  • Fax: 205-271-3075

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number14105
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: