Healthcare Provider Details

I. General information

NPI: 1659352763
Provider Name (Legal Business Name): SETH ALFRED FAGERLIE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2005
Last Update Date: 11/12/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5102 W CAMPBELL AVE
PHOENIX AZ
85031-1703
US

IV. Provider business mailing address

26078 N 71ST DR
PEORIA AZ
85383-7318
US

V. Phone/Fax

Practice location:
  • Phone: 623-848-5000
  • Fax:
Mailing address:
  • Phone: 623-362-3733
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number33539
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: