Healthcare Provider Details

I. General information

NPI: 1487695144
Provider Name (Legal Business Name): SUSAN BETH FAGES LIC-A
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2006
Last Update Date: 07/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 HOSPITAL BLVD SUITE 450
ROSWELL GA
30076-4907
US

IV. Provider business mailing address

2500 HOSPITAL BLVD SUITE 450
ROSWELL GA
30076-4907
US

V. Phone/Fax

Practice location:
  • Phone: 770-343-8675
  • Fax: 770-343-8126
Mailing address:
  • Phone: 770-343-8675
  • Fax: 770-343-8126

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number3457
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: