Healthcare Provider Details

I. General information

NPI: 1801061320
Provider Name (Legal Business Name): BRANDIE LYNN FAGIN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2008
Last Update Date: 03/07/2024
Certification Date: 03/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1725 W HARRISON ST STE 717
CHICAGO IL
60612-3863
US

IV. Provider business mailing address

1725 W HARRISON ST STE 717
CHICAGO IL
60612-3863
US

V. Phone/Fax

Practice location:
  • Phone: 312-563-3270
  • Fax:
Mailing address:
  • Phone: 312-563-3270
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number036-120912
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: