Healthcare Provider Details

I. General information

NPI: 1588689236
Provider Name (Legal Business Name): FAGAN ER MEDICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2006
Last Update Date: 12/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1225 WILSHIRE BOULEVARD
LOS ANGELES CA
90017-2395
US

IV. Provider business mailing address

520 N CENTRAL AVE SUITE 750
GLENDALE CA
91203-1926
US

V. Phone/Fax

Practice location:
  • Phone: 213-482-2741
  • Fax:
Mailing address:
  • Phone: 818-557-0135
  • Fax: 818-557-1394

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. PHILIP J. FAGAN JR.
Title or Position: PRESIDENT
Credential: M.D.
Phone: 818-557-0135