Healthcare Provider Details

I. General information

NPI: 1164604427
Provider Name (Legal Business Name): FAGMAN EYE SURGERY ASSOC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2007
Last Update Date: 11/28/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 E COUNTRYSIDE PKWY
YORKVILLE IL
60560-1877
US

IV. Provider business mailing address

120 E COUNTRYSIDE PKWY
YORKVILLE IL
60560-1877
US

V. Phone/Fax

Practice location:
  • Phone: 630-553-6166
  • Fax: 630-553-6178
Mailing address:
  • Phone: 630-553-6166
  • Fax: 630-553-6178

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number StateIL

VIII. Authorized Official

Name: MRS. MARY E MELICK
Title or Position: OFFICE MANAGER
Credential: COA
Phone: 630-553-6166