Healthcare Provider Details

I. General information

NPI: 1477584092
Provider Name (Legal Business Name): ROBERT JAMES FAGERHOLM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 4TH ST SW
MASON CITY IA
50401-2800
US

IV. Provider business mailing address

24151 HAZEL RD
ELKPORT IA
52044-8320
US

V. Phone/Fax

Practice location:
  • Phone: 641-422-7000
  • Fax:
Mailing address:
  • Phone: 563-245-1547
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number31364
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: