Healthcare Provider Details

I. General information

NPI: 1962559732
Provider Name (Legal Business Name): DANIEL PATRICK FAGIN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2007
Last Update Date: 12/10/2021
Certification Date: 12/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2650 RIDGE AVE. DEPT. OF ANESTHESIOLOGY
EVANSTON IL
60201
US

IV. Provider business mailing address

2650 RIDGE AVE. DEPT. OF ANESTHESIOLOGY
EVANSTON IL
60201
US

V. Phone/Fax

Practice location:
  • Phone: 847-570-2760
  • Fax: 847-570-2921
Mailing address:
  • Phone: 847-570-2760
  • Fax: 847-570-2921

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number222519
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number036120731
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: