Healthcare Provider Details

I. General information

NPI: 1821110396
Provider Name (Legal Business Name): DONALD FAGERSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2007
Last Update Date: 03/31/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1644 W COLONIAL PKWY
INVERNESS IL
60067-1207
US

IV. Provider business mailing address

1644 W COLONIAL PKWY
INVERNESS IL
60067-1207
US

V. Phone/Fax

Practice location:
  • Phone: 847-358-1588
  • Fax: 847-358-1542
Mailing address:
  • Phone: 847-358-1588
  • Fax: 847-358-1542

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number036085741
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: